B80. AMTSL Learnerguidebook Final

Prevention of
postpartum
hemorrhage: Active
management of the
third stage of labor
Learner’s Guidebook
for on-site and
individual (SAIN)
learning approach
Copyright © 2009. Program for Appropriate Technology in Health (PATH). All rights
reserved. The material in this document may be freely used for educational or
noncommercial purposes, provided that the material is accompanied by an acknowledgment
line.
This guide was adapted with permission from:

- Self-paced learning materials developed by the PRIME II project, a USAID project led by
IntraHealth International, Inc. Harber L, Engelbrecht SM, Murphy C. Self-Paced Learning
Course in Prevention of Postpartum Haemorrhage Initiative. IntraHealth International,
Inc: Chapel Hill, January 2004.
- POPPHI. Prevention of postpartum hemorrhage: Active management of the third stage of
labor: Reference Manual. Seattle: PATH; 2007.
Suggested citation: POPPHI. Prevention of postpartum hemorrhage: Active management of

the third stage of labor: Learner’s Guidebook for on-site and individual (SAIN) learning
approach. Seattle: PATH; 2009.
Prevention of postpartum hemorrhage: Active

management of the third stage of labor
(AMTSL)
Learner’s Guidebook for

on-site and individual (SAIN) learning approach
2009
Prevention of Postpartum Hemorrhage

Initiative (POPPHI)
Development of these learning materials is made possible through support provided to the
POPPHI project by the Office of Health, Infectious Diseases and Nutrition, Bureau for Global
Health, US Agency for International Development, under the terms of Subcontract No. 4-31-
U-8954, under Contract No. GHS-I-00-03-00028. POPPHI is implemented by a collaborative
effort between PATH, RTI International, and EngenderHealth.
POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

SAIN learning approach iii
Table of contents
Introduction ............................................................................................................. xi
Prevention of Postpartum Hemorrhage Initiative .................................................... xii
Why focus on preventing PPH? ............................................................................. xii
What can be done to prevent PPH? ...................................................................... xiii
Blended learning approach for AMTSL ......................................................................... xv
Goal ................................................................................................................. xv
Objectives ......................................................................................................... xv
Contents of the course ........................................................................................ xv
How does the blended learning course work? ........................................................ xvi
Course materials ...............................................................................................xvii
Support for learners .........................................................................................xviii
Assessment of progress ....................................................................................xviii
Learning clinical skills ........................................................................................ xix
Directions for self-study ....................................................................................xxiv
Suggested prevention of postpartum hemorrhage (PPPH) course schedule .............. xxv
Meaning of symbols/icons used in the Learner’s Guidebook and Learner’s Notebookxxviii
Core Topic 1: Third stage of labor and evidence for using AMTSL .....................................1
Overview.............................................................................................................1
Learning objectives ..............................................................................................1
Key definitions .....................................................................................................1
Significance of the third stage of labor ....................................................................3
Anatomy and physiology of the third stage of labor ..................................................3
Approaches for managing the third stage of labor ....................................................6
Scientific evidence supporting use of AMTSL ............................................................7
Summary ............................................................................................................8
Core Topic 2: Prevention of postpartum hemorrhage ......................................................9
Overview.............................................................................................................9
Learning objectives ..............................................................................................9
Key definitions .....................................................................................................9
Introduction ...................................................................................................... 10
Causes of PPH.................................................................................................... 10
Factors contributing to uterine atony .................................................................... 11
PPH prevention and early detection ...................................................................... 12
Summary .......................................................................................................... 15
Core Topic 3a: Review of uterotonic drugs................................................................... 17
Overview........................................................................................................... 17
Learning objectives ............................................................................................ 17
Key definitions ................................................................................................... 17
Use of uterotonics .............................................................................................. 18
Uterotonic drugs used for AMTSL.......................................................................... 20

iv SAIN learning approach
Recommendations for selection of a uterotonic drug for prevention of PPH ................ 22

Summary .......................................................................................................... 23
Core Topic 3b: Managing uterotonic drugs................................................................... 25
Overview........................................................................................................... 25
Key definitions ................................................................................................... 25
Management of uterotonic drugs .......................................................................... 26
General rules ..................................................................................................... 26
Procurement...................................................................................................... 28
Keeping uterotonic drugs effective........................................................................ 34
Tips to increase uterotonic drug effectiveness ........................................................ 35
Summary .......................................................................................................... 38
Core Topic 4: AMTSL ................................................................................................ 39
Overview........................................................................................................... 39
Key definitions ................................................................................................... 39
Essential care during the third stage of labor ......................................................... 40
Essential care for the newborn ............................................................................. 40
Preparing for active management......................................................................... 42
Steps for AMTSL ................................................................................................ 43
Care after delivery of the placenta........................................................................ 49
Care for the woman............................................................................................ 51
Care for the newborn.......................................................................................... 52
Document findings and care provided ................................................................... 53
Monitoring the woman 0-6 hours after delivery of the placenta ................................ 53
Monitoring the newborn 0-6 hours after delivery of the placenta .............................. 54
Examinations of the woman and newborn one hour after delivery of the placenta....... 56
Management of the third stage of labour when the birth attendant is alone and the
baby needs resuscitation ..................................................................................... 58
Management of the third stage of labour in the context of HIV ................................. 59
Frequently asked questions ................................................................................. 60
Summary .......................................................................................................... 64
Additional Topic 1: Prevention of infections.................................................................. 65
Overview........................................................................................................... 65
Key definitions ................................................................................................... 65
Principles of infection prevention .......................................................................... 66
Handwashing ..................................................................................................... 66
Gloves .............................................................................................................. 68
Aprons or gowns ................................................................................................ 69
Handling sharp instruments ................................................................................. 70

SAIN learning approach v
Preventing splashes............................................................................................ 70
Waste disposal................................................................................................... 71
The steps of processing instruments ..................................................................... 72
Making a chlorine decontamination solution ........................................................... 74
Summary .......................................................................................................... 78
Additional Topic 2: Birth preparedness and complication readiness ................................. 79
Overview........................................................................................................... 79
Key definitions ................................................................................................... 79
Introduction ...................................................................................................... 80
Birth-preparedness plan (BPP) ............................................................................. 80
Delays resulting in maternal and newborn deaths................................................... 81
Complication-readiness plan (CRP) ....................................................................... 82
Summary .......................................................................................................... 85
Additional topic 3: Managing complications during the third stage of labor ...................... 87
Overview........................................................................................................... 87
Key definitions ................................................................................................... 87
General management for an obstetric emergency................................................... 88
Job Aid: Managing obstetric emergencies General management for shock ................ 89
General management for shock............................................................................ 90
Job Aid: Managing shock ..................................................................................... 92
General management for vaginal bleeding after childbirth ....................................... 93
Job Aid: Managing vaginal bleeding after childbirth................................................. 94
Diagnosis of vaginal bleeding after childbirth ......................................................... 95
Job aid: Specific management for PPH .................................................................. 96
Management of uterine atony .............................................................................. 97
Management of tears in the birth canal ............................................................... 100
Management of retained placenta....................................................................... 102
Management of retained placental fragments....................................................... 103
Management of uterine inversion ....................................................................... 104
Management if the cord tears off during CCT ....................................................... 105
Summary ........................................................................................................ 106
Suggested answers to learning activities ................................................................... 107
Core Topic 1: Third stage of labor and evidence for using AMTSL ........................... 107
Core Topic 2: Prevention of postpartum hemorrhage ............................................ 109
Core Topic 3a: Review of uterotonic drugs........................................................... 111
Core Topic 3b: Managing uterotonic drugs........................................................... 114
Core Topic 4: AMTSL ........................................................................................ 121
Additional topic 1: Prevention of infections .......................................................... 125
Additional topic 2: Birth preparedness and complication readiness.......................... 129
Additional topic 3: Managing complications during the third stage of labor .............. 135

vi SAIN learning approach
Appendix A: FIGO/ICM joint statements .................................................................... 145

Bibliography .......................................................................................................... 155
Endnotes............................................................................................................... 158
List of figures
Figure 1-1. Muscle fibers of the uterus. .........................................................................4
Figure 1-2. Placenta attachment to uterus showing maternal blood vessels .......................4
Figure 1-3. Placenta falling into lower uterine segment ...................................................5
Figure 1-4. Empty uterus ............................................................................................5
Figure 3-1. The UnijectTM device................................................................................. 21
Figure 3-2. Importance of quantifying and ordering drugs regularly................................ 33
Figure 3-3. Reading the time-temperature indicator ..................................................... 37
Figure 4-1. Keeping the baby in skin-to-skin contact with the mother. ............................ 41
Figure 4-2. Preparing oxytocin injection. ..................................................................... 42
Figure 4-3. Put the baby on the mother’s abdomen. ..................................................... 43
Figure 4-4. Rule out the presence of a second baby...................................................... 43
Figure 4-5. Give a uterotonic drug.............................................................................. 44
Figure 4-6. Pulsating and nonpulsating umbilical cord. .................................................. 44
Figure 4-7. Keep the baby in skin-to-skin contact with the mother. ................................ 45
Figure 4-8. Clamping the umbilical cord near the perineum. .......................................... 45
Figure 4-9. Palpate the next contraction...................................................................... 46
Figure 4-10. Applying CCT with countertraction to support the uterus. ............................ 46
Figure 4-11. Supporting the placenta with both hands. ................................................. 47
Figure 4-12. Delivering the placenta with a turning and up-and-down motion. ................. 47
Figure 4-13. Massaging the uterus immediately after the placenta delivers...................... 48
Figure 4-14. Teach the woman how to massage her own uterus..................................... 48
Figure 4-15. Examining the maternal side of the placenta. ............................................ 49
Figure 4-16. Checking the membranes........................................................................ 49
Figure 4-17. Gently inspect the lower vagina and perineum for lacerations. ..................... 50
Figure 4-18. Encourage breastfeeding within the first hour after birth. ............................ 51
Figure 5-1. Washing hands. (EngenderHealth, online course:
http://www.engenderhealth.org/ip/handwash/hw6.html) .............................................. 67
Figure 5-2. Putting gloves on. .................................................................................... 68
Figure 5-3. Removing gloves. .................................................................................... 69
Figure 5-4. One-hand technique for needle recapping. .................................................. 70

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Figure 5-5. Steps in process instruments..................................................................... 72
Figure 7-1. Bimanual compression of the uterus........................................................... 98
Figure 7-2. Compression of abdominal aorta and feeling the femoral pulse. ..................... 99
Figure 7-3. Common positions for cervical tears. ........................................................ 100
Figure 7-4. Repairing a cervical tear. ........................................................................ 101
Figure 7-5. Manual reduction of an inverted uterus..................................................... 104
List of tables
Table 1-1. Comparison of physiologic and active management of the third stage of labor
(AMTSL)....................................................................................................................6
Table 1-2. Bristol and Hinchingbrooke study results comparing active and physiologic
management of the third stage of labour.......................................................................7
Table 3-1. Uterotonic drugs for AMTSL ........................................................................ 20
Table 3-2. Recommended guidelines for transport and storage of uterotonic drugs........... 34
Table 3-3. Change in effectiveness of injectable uterotonic drugs after one year of controlled
storage ................................................................................................................... 35
Table 5-1. Steps and benefits for processing instruments for reuse ................................ 73
Table 5-2. Mixing a 0.5 percent chlorine decontamination solution ................................. 76
Table 7-1. Diagnosis of vaginal bleeding after childbirth ................................................ 95
Table 7-2. Uterotonic drugs for PPH management ........................................................ 97

viii SAIN learning approach
Acknowledgments
POPPHI learning materials for training in AMTSL were adapted by Susheela M. Engelbrecht
for use with the on-site and individual (SAIN) learning approach.
Format for the guide and key content on self-paced learning were adapted with permission
from the self-paced learning materials developed the PRIME II project, a USAID project led
by IntraHealth International, Inc. Harber L, Engelbrecht SM, Murphy C. Self-Paced Learning
Course in Prevention of Postpartum Haemorrhage Initiative. IntraHealth International, Inc:
Chapel Hill, January 2004.
Illustrators: Andri Burhans and Sidy Lamine Dramé
Proofreader: Rachel Moorhead
About POPPHI
The Prevention of Postpartum Hemorrhage Initiative (POPPHI) is a USAID-funded, five-year
project focusing on the reduction of postpartum hemorrhage, the single most important
cause of maternal deaths worldwide. The POPPHI project is led by PATH and includes four
partners: RTI International, EngenderHealth, the International Federation of Gynaecology
and Obstetrics (FIGO), and the International Confederation of Midwives (ICM).
For more information or additional copies of this manual, please contact:
Deborah Armbruster, Project Director, or
Susheela M. Engelbrecht, Senior Program Officer
PATH
1800 K St., NW, Suite 800
Washington, DC 20006
Tel: 202.822.0033
www.pphprevention.org

SAIN learning approach ix
Acronyms
AMTSL active management of the third stage of labor

ARV antiretroviral
BPP birth-preparedness plan
CCT controlled cord traction
CRP complication-readiness plan
DIC disseminated intravascular coagulopathy
FEFO first to expire first out
FIFO first in first out
FIGO International Federation of Gynaecology and Obstetrics
HLD high-level disinfection
ICM International Confederation of Midwives
IM intramuscular
IP infection prevention
IU international units
IV intravenous
mcg micrograms
MTCT mother-to-child transmission (of HIV/AIDS)
N/A not applicable
PMTCT prevention of mother-to-child transmission (of HIV/AIDS)
PMTSL physiologic management of the third stage of labor
POPPHI Prevention of Postpartum Hemorrhage Initiative
PPH postpartum hemorrhage
PPPH prevention of postpartum hemorrhage
RI request indicator
SAIN on-site and individual learning approach
TTI time-temperature indicator
USAID United States Agency for International Development
VVM vaccine vial monitor
WHO World Health Organization

x SAIN learning approach
Introduction
In many developing countries, national health statistics are characterized by high rates
of maternal morbidity and mortality. Complications during pregnancy and childbirth are
the most significant causes of death among women of reproductive health age. Less
than one percent of these deaths occur in more developed countries, showing that the
large majority of these deaths can be prevented if there are sufficient resources and
health services available.
Most maternal deaths are attributable to direct causes. Direct maternal deaths follow
complications of pregnancy and childbirth, or are caused by any interventions,
omissions, incorrect treatment or events that result from these complications. The five
major direct causes are hemorrhage, infection, eclampsia, obstructed labor, and unsafe
abortion (see Figure 1). The levels of maternal mortality depend on whether these
complications are dealt with adequately and in a timely manner.
Figure 1. Global Data: Causes of Maternal Death (2005). (WHO, 1999)

Notes: (1) Other direct causes include ectopic pregnancy, embolism,
anesthesia-related. (2) Indirect causes include: anemia, malaria, heart
disease, HIV/AIDS.
More than half of these maternal deaths occurring globally do so in the first 24 hours
after childbirth, and most of these deaths are due to postpartum hemorrhage. 1,2
Postpartum hemorrhage (PPH) or excessive bleeding after childbirth is the single most
important direct cause of maternal deaths in developing countries. Approximately 25
percent of all maternal deaths are due to hemorrhage; with percentages varying from
less than 10 percent to almost 60 percent in different countries. Postpartum bleeding
can kill even a healthy woman within two hours, if unattended. It is the quickest of
maternal killers. Even if a woman survives a PPH, she could be severely anemic and
suffer chronic health problems.
The proportion needing hospital care depends, to some extent, on the quality of the
first-level care provided to women; for example, active management of the third stage

SAIN learning approach xi
of labor reduces total blood loss, incidence of retained placenta, length of third stage,
and PPH.3–4 An injection of oxytocin given immediately after the baby is born is very
effective in reducing the risk of bleeding. If a woman has bleeding after childbirth, she
requires urgent care which may include a fairly simple—but urgent—intervention such as
uterotonic drugs (oxytocin) and uterine massage for uterine atony, manual removal of
the placenta, or suturing of genital lacerations. Other women may need a surgical
intervention or a blood transfusion, both of which require hospitalization with
appropriate staff, equipment, and supplies. The proportion of women who die depends
on whether appropriate care is provided rapidly.
Prevention of Postpartum Hemorrhage Initiative (POPPHI)

Fortunately, research shows that using simple, low-cost interventions can help avoid
most of these tragic outcomes. Current evidence indicates active management of the
third stage of labor (AMTSL)—including administration of uterotonic drugs, controlled
cord traction, and fundal massage after delivery of the placenta—can reduce the
incidence of postpartum hemorrhage by up to 60 percent in situations where:
• National guidelines support the use of AMTSL.
• Health workers receive training in using AMTSL and administering
uterotonic drugs.
• Injection safety is ensured.
• Necessary resources (uterotonic drugs and cold chain for storage of
uterotonic drugs; equipment, supplies, and consumables for infection
5
prevention and injection safety) are available.
Ongoing research in various settings continues to identify the best approaches for
preventing and managing postpartum bleeding and its complications. By developing
national guidelines, training skilled birth attendants, improving work environments of
skilled providers, and supporting the development of improved access to care, more
women will have access to this lifesaving intervention.
Why focus on preventing PPH?
International and national programs focus on preventing PPH because:

• Every year there are 14 million cases of obstetrical hemorrhage, most of which occur
in the postpartum period.
• PPH is the single most important cause of maternal death worldwide. It accounts for
20 to 60 percent of maternal deaths.
• For severely anemic women, blood loss as little as 200 to 250 mL can be fatal.
• Predicting who will have PPH based on risk factors is difficult because two-thirds of
women who have PPH have no risk factors.6
• Preventing PPH will significantly reduce maternal mortality and morbidity.
• There is scientific evidence that AMTSL is a low-cost, evidence-based practice that
can prevent up to 60 percent of PPH cases and improve maternal survival, which is
linked to infant survival.

xii SAIN learning approach
What can be done to prevent PPH?

In the community:
• Families and caregivers, together with pregnant women, can develop birth
preparedness and complication readiness plans, including actions to take when there
is excessive bleeding during labor and childbirth.
• Pregnant women and their families and caretakers can be educated about the
importance of having birth attendants skilled in prevention and control of bleeding
during childbirth.
• Resources can be mobilized for rapid transfer of women with excessive bleeding to
essential obstetric care facilities for appropriate care.
At health facilities:
Facilities can implement active management of the third stage of labor, a process
aimed at accelerating delivery of the placenta and contraction of the uterus through:
• Administering a uterotonic drug within one minute of birth.
• Applying controlled cord traction with counter-traction to the uterus.
• Massaging the fundus of the uterus through the abdomen.
“The third stage of labor is the period between the

birth of the infant and delivery of the placenta.”

SAIN learning approach xiii
xiv SAIN learning
approach
Blended learning approach for AMTSL
Goal
This training in active management of third stage of labor will assist you to provide the
crucial care needed to prevent PPH, and apply this new knowledge and these skills to
improving the clinical services you provide and to training other providers.
Objectives
The mentors will help you learn to:
• Give safe, respectful, and friendly care to mothers and families, thereby
encouraging mothers and families to return for care again and again.
• Follow a suggested protocol for safe care during delivery, including active
management of third stage of labor, and in the immediate postpartum,
including clear guidelines on times for referral with a complication, so that
timely action is taken.
• Provide greater protection from infection for their clients and themselves.
• Store uterotonic drugs in such a way that their potency is maintained and
ensured.
• Store uterotonic drugs in such a way that their availability is always
guaranteed.
All of these components can improve the quality of care that you provide and will lead to
a healthier outcome for women, who are mothers, wives, and important members of the
community.
Contents of the course

The Learners’ Guidebook contains seven topics:
The core topics are:
• Review of the third stage of labor and evidence for use of AMTSL.
• Causes and prevention of PPH.
• Review and management of uterotonic drugs.
• AMTSL.
Additional topics that some countries may include during the training include:
• Infection prevention.
• Birth preparedness and complication readiness.
• Managing complications during the third stage of labor.
While you can complete all seven of them, your mentor will tell you which of the topics
you are required to complete.

SAIN learning approach xv
How does the blended learning course work?
The blended learning course in prevention of postpartum hemorrhage (PPPH) has four
parts:
1. A one-day group orientation to acquaint you with the concept of self-paced
learning, the PPPH course, the learner materials and the learner support system.
During the orientation, you will also complete a pre-course questionnaire to
determine what you already know and the areas related to PPPH where you need
the most assistance.
2. Self-study on your own, using the Learner’s Guidebook and Notebook and in-
built learning activities. The Learner’s Guidebook is designed in a special way to
enable you to use it for learning by doing assignments and in-built activities
which you mark yourself, or complete with help from co-workers, in-charges or
mentors. If there are other midwives in your clinic who are taking this course,
you can work together as learning partners on the in-built activities. This part of
the course usually takes about three to four weeks.
3. Mid-course assessment and clinical skills practice. When you have
successfully completed the theory portion of the course by working through the
Learner’s Guidebook, the next step will be to arrange with your mentor to take
the mid-course questionnaire and use practice checklists and anatomical models
to practice demonstrating clinical skills.
When the mentor has found that you can competently perform the newly
acquired skills on models, he/ will then send you into the clinical area to gain
competency and proficiency in the skills acquired. You will observed and, when
possible, apply the newly gained knowledge and skills in a real clinical setting.
Clinical preceptors will supervise the practice in the clinical area, but ward staff
will be guiding, coaching, and mentoring you through the training.
4. Once you have been observed doing critical skills correctly in the clinical area,
you can take the post-course questionnaire. When you have passed the post-
course questionnaire and developed an action plan, you qualify for a certificate.
The diagram below summarizes the structure of the self-paced learning course,
and the text that follows gives more details about each component of the course.
Self-Paced Learning Course on Prevention of Postpartum Hemorrhage
• Group orientation to the self-paced learning course
1 day
• Pre-course questionnaire
2–4 • Self-study with Study Booklet, learning activities and

weeks learning partner/co-workers

xvi SAIN learning
approach
• Group review of learning activities with mentor

• Mid-course questionnaire
• Skill demonstration and assessment on models
• Clinical practice
1–2 days
• Clinical skills assessment in the clinical area
• Post-course questionnaire
• Action plan
• Course evaluation
Course materials
The on-site and individual (SAIN) learning package on the prevention of PPH consists of
a Learner’s Guidebook and a Learner’s Notebook. This learning package was developed
for use by nurses, midwives, and doctors providing childbirth and immediate postpartum
care. These documents comprise a set and should be used together. These resources are
distinguished within the series by a corresponding icon located at the top of the right
hand page:
Learner’s Notebook
These learning materials were developed for in-service training of skilled birth
attendants using a mixed-learning approach that combines self-paced study for the
theoretical portion of the course followed by a clinical practicum. This training
course should assist providers to provide the crucial care needed to prevent
postpartum hemorrhage.
The Learner’s Guidebook is the basic text of the course. It contains information to be
learned, reading assignments, and it guides you as to how you should study the topics.
Think of it as your “teacher” or “mentor.”
The Learner’s Notebook contains activities that you must complete, job aids, and
practice checklists to help you learn the correct steps (and sequence, if necessary)
required to perform a skill. The notebook has the following components:
• Forms to record knowledge and skills assessment scores.
• Learning activities for each topic.
• Practice checklist for AMTSL and monitoring during the first six hours postpartum.
• Evaluation checklist for AMTSL and monitoring during the first six hours postpartum.
• Job aids for storage and documentation of uterotonic drugs, AMTSL, and monitoring
the woman and newborn during the first six hours postpartum.
• Evaluation of the in-service training program.
• Action plan.

SAIN learning approach xvii
Support for learners
“Learner Support System” is the name for the many ways that a self-paced learning
program assists you while you complete a course. These strategies help ensure that you
as a learner are motivated to complete your course and achieve the desired learning.
Your learner support system includes:
• Assigning each learner a mentor who will assist with your orientation to the course
and materials, demonstration and return demonstration on models, testing, and
clinical skills assessment.
• Orienting the in-charge at your facility so that she can help you get the resources
you need for your course, including free time for studying, help you with your
learning, and opportunities for you to use the skills you are learning at your job.
• Providing specially designed Learner’s Guidebook and Notebook that help you to
learn on your own.
• Providing regular feedback on how you are doing from your mentor, in-charge and
your Learner’s Notebook.
• Encouraging you to share ideas and work on activities with your co-workers/learning
partner.
Assessment of progress
Learners completing a self-paced learning course need to know how well they are doing.
This course uses a number of methods to let learners know how they are doing in the
course. These include a pre-course questionnaire, in-built activities, a mid-course
questionnaire, critical skill observations, and a post-course questionnaire. These
methods are described below.
Pre-course questionnaire
This is a questionnaire you take before you begin the course to help you identify the
areas where you need the most assistance. A pre-course questionnaire is made up of
several questions covering the main concepts or topics in the course. As you work
through the course, put emphasis on areas where you did not do very well in your pre-
course questionnaire.
In-built activities
These are activities that are part of your Study Booklet. They include a variety of
questions, checklists, role plays, etc. designed to help you learn the content. They act
like a teacher asking a question in class or challenging you to try a new skill. They are
intended to help you learn the subject and let you know how well you understand what
you learn.
You should make sure that you attempt all the activities, answer questions and mark
them yourself to see how well you learned. All of the answers to the activities are
located in the back of your Study Booklet, but if you have any problems or questions
about the activities, you will have an opportunity to review them with your mentor
before taking the mid-course questionnaire. If there are other nurses or midwives in
your clinic who are taking this course, you can work together as learning partners on the
in-built activities.
REMEMBER: Complete all the activities in your Study Booklet and self-mark
(correct) the in-built activities.

xviii SAIN learning
approach
Mid-course questionnaire
When you have completed the Study Booklet objectives, your mentor will administer the
mid-course questionnaire. The objectives of this questionnaire are similar to the pre-
course questionnaire: assist you and your mentor to identify topics that may need
additional emphasis during the clinical experience and assist you in focusing on your
individual learning needs.
After completing and correcting the mid-course questionnaire, you and your mentor will
go over answers that were incorrectly answered to clarify the subject and try to facilitate
bridging gaps in knowledge.
Critical skill learning and observations
When you have completed the mid-course questionnaire, you are ready to work with
your mentor on critical skill demonstrations and return demonstrations on anatomical
models, following the practice checklists in your Learner’s Notebook. Critical skills are
important skills that you must learn to do correctly in order to pass the course.
After you have learned a critical skill, you must show your mentor that you can do this
skill correctly. Using the evaluation checklist found in your Learner’s Notebook, your
mentor will observe you and “approve” that you can do these important skills on
anatomical models.
After being found competent to perform the critical skills during demonstrations on
anatomical models, you will then practice these skills in the clinical area. Your practice
will be supervised and assessed by an experienced provider while performing the skills
until you are found competent.
Post-course questionnaire
This is a test you take at the end of the course after completing your clinical practice. It
is to help you figure out how much you have gained from your course. After you have
passed the post-course questionnaire and have been observed doing critical skills
correctly, you qualify for a certificate. If the post-course questionnaire shows that there
are knowledge and skills that you have not yet mastered, you can continue to work on
them. After completing the post-course questionnaire, you and your mentor will
complete an action plan to help ensure that your new skills are transferred to the job.
Learning clinical skills

Demonstrations and return demonstrations on models
When you have successfully completed the mid-course questionnaire, you will work with
your mentor on demonstrations and return demonstrations with anatomical models
using the practice checklists. When your mentor has found that you can competently
perform the newly acquired skills on models, she will then introduce you to the clinical
area to gain competency and proficiency in the skills acquired.
While learning skills, you will use the practice checklists found in your Learner’s
Notebook. A practice checklist contains the individual steps or tasks in sequence
required to perform a skill or activity in a standardized way. Practice checklists are
designed to help you learn the correct steps and sequence in which they should be
performed, and its rating scale records progressive learning in small steps as you gain
confidence and skill.
An important part of competency-based training is learning clinical skills through
demonstrations and return demonstrations on an anatomical model. Your mentor will

SAIN learning approach xix
coach you while you are learning the skill by using positive feedback, active listening,
questioning, and problem-solving skills to encourage a positive learning environment. To
use coaching, the mentor will first explain the skill and then demonstrate it using an
anatomical model, while following the steps outlined on the practice checklist. Once
the procedure has been demonstrated and discussed, you will then practice the skill on
the model and perform a return demonstration while the mentor observes and interacts
with you and your fellow learners to provide guidance in learning the skill or activity,
monitors progress, and helps you overcome problems.
The coaching process ensures that you receive feedback regarding your performance:
• Before practice: you and your mentor should meet briefly before each practice
session to review the learning guide, including the steps/tasks that will be
emphasized during the session.
• During practice: your mentor observes, coaches and provides feedback to you as
you perform the steps/tasks as outlined in the learning guide.
• After practice: this feedback session should take place immediately after practice.
Using the learning guide, your tutor/mentor discusses the strengths and weaknesses
of your performance and also offers suggestions for improvement.
While learning a clinical skill, you will use the “team system.” A team system is a system
in which two learners work together as a team when they are practicing on an
anatomical model. When using this system the team members take turns being the
person that either “performs” a skill or “assists” with a skill. When working with teams,
the “assistant” will also help remind her partner when she forgets something or does not
remember how to do it correctly. The responsibilities of each team member include the
following.
Learner who “PERFORMS” the skill:
1. Reviews the appropriate practice checklist before performing the skill.
2. Performs the skill.
3. Evaluates herself using the practice checklist before the evaluation meeting with the
tutor/mentor or clinical preceptor.
4. Has an informal meeting to listen to and discuss with the tutor/mentor or clinical
preceptor about the evaluation of her performance.
Learner who “ASSISTS” with the skill:
1. Reviews the appropriate practice checklist before assisting with the skill.
2. Observes the person “performing” the skill and reminds her of any forgotten step.
3. Evaluates the person “performing” the skill using the practice checklist.
4. Has an informal meeting to discuss with the team “performer” about the evaluation
of the skill with which she assisted.
Before you attempt a clinical procedure with a client, three learning activities should
occur:
1. Your mentor should demonstrate the required skills and client interactions several
times using an anatomic model, while you and your fellow learners observe and
follow the learning guide for the demonstrated skill.
2. While being supervised, you should practice the required skills and client interactions
using the practice checklist, anatomical model and actual instruments in a simulated
setting which is as similar as possible to the real situation.
3. Your mentor should evaluate your ability to perform the skill on an anatomical model
using the evaluation checklist.

xx SAIN learning approach
Learning clinical skills at the clinical site

Once you can demonstrate the skills on models, you will observe and, when possible,
apply the newly gained knowledge and skills in a real clinical setting. Clinical preceptors
will supervise your clinical training, but ward staff will be guiding, coaching, and
mentoring you through the training
While in clinical, you will continue to use the “team system” when you are doing your
clinical experience on a unit or on-call. When using this system the team members take
turns being the person that either “performs” a skill or “assists” with a skill. This system
will help you learn more from all clinical experiences, those that you do and those that
you watch. You can also take turns caring for the woman and caring for the baby.
Evaluating clinical skills on models and in the clinical area
You and your mentor or clinical preceptor will keep track of progress in becoming
competent on models and in the clinical area by using evaluation checklists. The
evaluation checklist generally is derived from a practice checklist. Unlike practice
checklists, which are quite detailed, competency-based evaluation checklists focus only
on the key steps or tasks. The evaluation checklist contains enough detail to permit the
mentor or clinical preceptor to evaluate and record the overall performance of the skill
or activity.
This is how your mentor or clinical preceptor will use checklists during your clinical
training:
• To ensure that you have mastered the critical clinical skills and activities, first
with models and then with clients
• To ensure that you and other learners will have your skills measured according
to the same standard
• To form the basis for follow-up observations and evaluations.
When evaluating your performance, your mentor will grade each step of the skill using
the following scale:
1= Satisfactory: Performs the step or task completely and

correctly.
0= Unsatisfactory: Unable to perform the step or task

completely or correctly.
0= Not observed: Step, task, or skill not performed by learner

during evaluation by mentor.
N/A = Not applicable: Step is not needed.
Your ability to competently carry out the skills being taught carries more weight than the
number of times you carry them out. Because the goal of this training is to enable every
participant to achieve competency, additional training or practice in these skills may be
necessary.
The evaluation checklist is first used to assess your performance on models. After you
demonstrate competency on models, you can then work with clients, and the evaluation
checklist is once again used to assess your performance.
When completed, this evaluation checklist, together with your mentor’s and clinical
preceptor’s comments and recommendations, provides objective documentation of your

SAIN learning approach xxi
level of performance. Furthermore, it serves as one part of the process of attesting that
you are qualified to provide the clinical service (e.g., active management of third stage
of labor) or activity (e.g., counseling on preparation of a birth preparedness plan).
Keeping track of demonstrations and clinical experience
You and your mentor keep track of how many times you have either “demonstrated” or
“observed” or “performed” a skill by marking your experiences on a wall tabulation chart
(see next page). Keeping track of your experiences will help you and your mentor
ensure the very best clinical experience for all of you.
• Your mentor will:
- Write the date you were found competent in a skill on an anatomical model in the
“demonstrated” column.
- Write the date you were found competent in a skill in the clinical in the
“performed” column.
• You will:
- Make a mark (a “| |”) under a skill each time you have observed another learner
or a provider performing the skill in the clinical area on a client.

xxii SAIN learning
approach
Wall Chart - Clinical experiences
Monitoring the woman and

Skill AMTSL newborn in the immediate
postpartum
Demonstrated
Performed
Performed
Observed
Observed
Learner
Prevention of postpartum hemorrhage initiative – 2009 – In-Service Training for Skilled Birth Attendants
SAIN learning approach (self paced + clinical practicum) xxiii
Directions for self-study

You are a learner. You have been a learner since the day you were born—learning to walk,
learning to speak, learning to read and write, and eventually learning to provide health care
services for clients. Some of this learning you did on your own, other times your parents,
friends, teachers, and supervisors helped you. The times when you decided to learn things
on your own you were doing “self-paced learning”—though you probably did not call it by
that name.
In this course, you will be directing your own learning. Rather than a teacher or a trainer
telling you what to do each study session, you will read your Learner’s Guidebook and
follow the suggestions for learning the content. Don’t worry, though. As we discussed
earlier, all self-paced learners have a learner support system to help them with problems
that they may encounter while learning. Whenever you have difficulty, get help from the
people in your learner support system.
Since you will be doing a lot of studying on your own, you need to have good personal
study skills. The following is some advice for studying and learning on your own:
• Reading is one of the most important skills in self-paced learning. Carefully read all of
the information in your Learner’s Guidebook. Read the learning objectives so that you
know why you are studying a unit. Slow, careful and repeated reading of information
can help you to learn it. When you are not sure about something, you can read to
search for specific information or answer a specific question. Use the glossary in the
Learner’s Guidebook to help yourself learn new terms.
• Think about what you are learning and look for ways to apply it in your daily tasks. As
you study, allow yourself some quiet time so that you can reflect on what you are
learning and gain understanding about how it can help you do your job.
• Practice new skills whenever you get the chance. The more you repeat something, the
easier it is to remember.
• Study when you know nothing is going to disturb you. It may be easiest to study at the
same time every day. For example:
- At your place of work after duty in the afternoon.
- At home when your children have gone to sleep.
- On the weekend when the children are outside playing.
- Early in the morning before you go to work or start work.
• Set deadlines for yourself about when you want to finish certain activities and/or topics
and stick to your schedule/plans. If you get sick or fall behind in your studies, talk with
your mentor and figure out how you can successfully complete the course.
• Plan to study for at least two hours, five days of the week. Look at the schedule on page
xxvi. Notice that each topic takes a different amount of time. Some activities and units
you may be able to do faster than the estimated time; others may take you longer. It is
expected that you will be able to complete the course in about two to four weeks.
• Where you study is very important, so you should try to get a space set aside for this
purpose. You should make sure you have everything you need. A study space should:
- Be a quiet place away from people talking, radios, TVs.
- Have a table or desk and chair or mat, a pen or pencil, a place for your Learner’s
Guidebook, and a lamp or electric light for working at night.

SAIN learning approach xxiv
• Do all the in-built activities, exercises and assignments.

• As much as possible, complete the units and activities in the order that they appear in
the Learner’s Guidebook. Sometimes you may need to skip over an exercise that
requires your mentor’s help if they are not scheduled to see you on that day. Make note
of it and go back to it when you see your mentor again.
• Write in your Learner’s Notebook. You should make notes that are meaningful to you
and highlight things you want to be sure to remember. Use the “Things to Ask My
Mentor” page at the end of each topic to write down important points and/or make
notes about things you want to discuss with your mentor. The more you write, the
easier it is for you and your mentor to check your progress and correct any problems
you may have. Write legibly, in whatever language you want, so your work can be read
easily and marked by your mentor. Check your spelling and grammar.
• If you are very interested in a topic, you might find it helpful to read other books or
study other materials. When you use other books and materials, make sure they are
current and contain correct information. Your mentor can help you identify good
sources.
• Keep your Learner’s Guidebook and Notebook together. When you finish the course you
can keep the Learner’s Notebook to refer to at work.
• As a self-paced learner, you may feel lonely with nobody to help you when you have a
problem. In addition to your mentor and learning partner, you may be able to identify
others who can help. Co-workers, other nurses or midwives who are taking the same
course (your learning partners), friends, and/or family may be able to help. For
example:
- You can discuss topics with your co-workers that seem difficult and/or interesting to
you.
- You can work together with other midwives who are taking the course, on some of
the in-built activities and share ideas about how to solve problems that you are
having.
- You can ask your family to watch your children while you study.
REMEMBER: Never think of dropping out of this course. We are here to

help you succeed.
Suggested prevention of postpartum hemorrhage (PPPH)

course schedule
The following table outlines the number of learning activities/exercises to complete and an
estimated time to complete each topic. The self-paced module has been designed to take
approximately two weeks (18 hours) to complete the core topics and two weeks (17 hours)
to complete the additional topics, per learner. The clinical practicum may take one to two
days for each learner to have sufficient experience to become competent in the clinical
setting.

SAIN learning approach xxv
Number of learning Estimated
Topic
activities/exercises time
Review of the third stage of labor and
2 2 hours
evidence for use of AMTSL.
Review of uterotonic drugs. 3 3 hours
Management of uterotonic drugs. 3 3 hours
Causes and prevention of postpartum
4 4 hours
hemorrhage.
AMTSL. 6 6 hours
Infection prevention. 6 6 hours
Birth preparedness and complication
readiness. 4 4 hours
Managing complications during the third

stage of labor. 7 7 hours
The suggested schedule for the PPPH course can be found on the next page. The schedule
assumes that each learner will study about two hours per day to work through the
activities/exercises for each topic.

xxvi SAIN learning approach
Core Topics
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Orientation Review of the
Review of
third stage of
Causes and prevention of uterotonic
Week 1 labor and Study and Review
postpartum hemorrhage. drugs.
evidence for
use of AMTSL.
Management of uterotonic
Week 2 AMTSL. Study and Review
drugs.
Mid-course questionnaire
Week 3
Demonstrations, return demonstrations, clinical practice – 1 to 2
days
Additional Topics
Birth preparedness and

Week x Infection prevention. Study and Review
complication readiness.
Week x Managing complications during the third stage of labor. Study and Review
Denotes days that you will be in group session with other learners.
SAIN learning approach (self paced + clinical practicum) xxvii
Meaning of symbols/icons used in the Learner’s Guidebook
and Learner’s Notebook
Learning Objectives: What you’re going to learn.
Reading: What you need to read to meet the learning

objectives
Exercises: Activities to help you learn.
Note taking: Write down important things.
The presence of your mentor is needed.
Congratulations! You have completed the topic!
xxviii SAIN learning approach (self paced + clinical practicum)
Core Topic 1: Third stage of labor and evidence for

using AMTSL
Overview
When reviewing the third stage of labor and evidence for using AMTSL, training participants
will:
• Review the structure and function of the uterus during the third stage of labor.
• Compare physiologic and active management of the third stage of labor
(AMTSL).
• Review evidence supporting the practice of AMTSL.
• Learn why it is important to include AMTSL in your practice.
Learning objectives
By the end of this topic, participants will have the knowledge to:
Describe the anatomy of the uterus.
Explain how the structure of the uterus helps stop bleeding.
Define AMTSL.
Define physiologic management of the third stage of labor (PMTSL).
Compare AMTSL and PMTSL.
Discuss evidence to support AMTSL.
Explain why AMTSL can save lives.
Number of learning activities for this topic: 2
Estimated time to complete this topic: 2 hours
Key definitions
Active management of the third stage of labor (AMTSL): A combination of
actions performed during the third stage of labor to prevent PPH. AMTSL speeds
delivery of the placenta by increasing uterine contractions and prevents PPH by
minimizing uterine atony. The components of AMTSL are:
1) Administration of a uterotonic agent within one minute after the baby is born after
ruling out the presence of another baby (oxytocin is the uterotonic of choice).
2) Controlled cord traction (CCT) with counter-traction to the uterus during a uterine
contraction.
3) Uterine massage immediately after delivery of the placenta to help the uterus
contract, as well as to assess uterine contraction.
Controlled cord traction (CCT): Traction on the cord during a contraction
combined with countertraction upward on the uterus with the provider’s hand placed
immediately above the symphysis pubis. CCT facilitates expulsion of the placenta
once it has separated from the uterine wall.

SAIN learning approach 1
Physiologic (expectant) management of the third stage of labor (PMTSL):
Management of the third stage of labor that involves waiting for signs of placental
separation and allowing for spontaneous delivery of the placenta aided by gravity
and/or nipple stimulation. The components of PMTSL are:
Waiting for signs of separation of the placenta (cord lengthening, small blood loss,
uterus firm and globular on palpation at the umbilicus).
Encouraging maternal effort to bear down with contractions and, if necessary, to
encourage an upright position.
Uterine massage after the delivery of the placenta as appropriate.
Retraction: The act of the uterine muscle pulling back. Retraction is the ability of
the uterine muscle to keep its shortened length after each contraction. Together with
contractions, retraction helps the uterus become smaller after the delivery of the
baby.
Stages of labor
• First stage of labor: The first stage of labor begins with the onset of contractions and
ends when the cervix is fully dilated (10 cm). This stage is divided into two phases,
known as latent and active phases of labor. During latent phase, the uterine cervix
gradually effaces (thins out) and dilates (opens). This is followed by active labor, when
the uterine cervix begins to dilate more rapidly and contractions are longer, stronger,
and closer together.
• Second stage of labor: The second stage of labor begins when the uterine cervix is
fully dilated and ends with the birth of the baby. This is sometimes referred to as the
pushing stage.
• Third stage of labor: The third stage of labor begins with birth of the newborn and
ends with the delivery of the placenta and its attached membranes.
• Fourth stage of labor (also known as the “immediate postpartum” period ):-
The fourth stage of labor begins with delivery of the placenta and goes from one to six
hours after delivery of the placenta, or until the uterus remains firm on its own. In this
stabilization phase, the uterus makes its initial readjustment to the nonpregnant state.
The primary goal is to prevent hemorrhage from uterine atony and the cervical or
vaginal lacerations.
Uterine atony: Loss of tone in the uterine muscle. Normally, contraction of the
uterine muscles compresses the uterine blood vessels and reduces blood flow,
increasing the chance of coagulation and helping to prevent bleeding. The lack of
uterine muscle contraction or tone can cause an acute hemorrhage. Clinically, 75 to
80 percent of PPH cases are due to uterine atony.7
Uterine massage: An action used after the delivery of the placenta in which the
provider places one hand on top of the uterus to rub or knead the uterus until it is
firm. Sometimes blood and clots are expelled during uterine massage.
Uterotonics: Substances that stimulate uterine contractions or increase uterine tone.

2 SAIN learning approach
Significance of the third stage of labor

The third stage of labor is usually uneventful, with delivery of the placenta
taking place without complications. During this stage of labor, however, the
woman may encounter complications that could lead to maternal morbidity
and mortality. The most common complication is PPH—vaginal bleeding in
excess of 500 mL that occurs less than 24 hours after childbirth.
PPH may cause or worsen anemia or deplete iron stores in women, causing weakness and
fatigue in severe cases. If severe, PPH may result in shock or maternal death. A blood
transfusion may help improve anemia in women and shorten hospital stays, but transfusion
carries risks of reaction and infection, and it is not universally available. Because many
health facilities lack an adequate supply of safe blood, PPH can often strain the resources of
the best blood banks.
PPH may increase the likelihood of other issues, such as:
The need for emergency anesthetic services.
Manual exploration or use of instruments inside the uterus (increasing the risk of
sepsis).
Prolonged hospitalization. New studies show that extended hospitalizations can cause
significant and long-term financial hardships for the woman and her family.
Delayed breastfeeding.
Additionally, women who have severe PPH and survive (“near misses”) are significantly
more likely to die in the year following the PPH.8
Anatomy and physiology of the third stage of labor

After the baby is born, the muscles of the uterus contract, helping the placenta to separate
from the uterine wall. The amount of blood lost depends on how quickly this happens, since
the uterus can contract more effectively after the placenta is expelled. If the uterus does
not contract normally (such as in uterine atony), the blood vessels at the placental site stay
open and hemorrhage results. Because the estimated blood flow to the uterus is 500 to 800
mL/minute at term, most of which passes through the placenta, severe postpartum
hemorrhage can happen within just a few minutes.
The muscle fibers of the uterus are in a crosshatch (criss-cross) pattern surrounding
maternal blood vessels (Figure 1-1). After the birth of the baby, these muscle fibers begin
to contract and retract. Oxytocin, a hormone secreted by the posterior pituitary gland,
stimulates uterine contractions. Oxytocin levels increase greatly in late pregnancy and even
more during labor and lactation.

Figure 1-1. Muscle fibers of the uterus.
(http://library.med.utah.edu/nmw/mod2/Tutorial2/uterine_vessels_fig71.html.)
During the third stage, uterine contractions continue causing the placenta to separate from
the uterine wall. Placental separation happens by contraction and retraction of the uterine
muscles, reducing the size of the placental area. This reduction in size of the uterus is
caused by retraction of the uterine muscle, a unique characteristic that helps maintain its
shortened length after each contraction.
As the placental area becomes smaller, the placenta begins to separate from the uterine
wall because, unlike the uterus, it is not elastic and
cannot contract and retract (Figure 1-2). At the
area where the placenta separates from the
uterus, a clot forms. This clot—known as a
retroplacental clot—collects between the uterine
wall and the placenta and further promotes
separation.
Additional uterine contractions complete the
separation of the placenta from the uterine wall.
After this occurs, the placenta descends into the
lower uterine segment and into the vagina where it
is expelled.
Figure 1-2. Placenta attachment to

uterus showing maternal blood
vessels

After separation:
The placental site is rapidly covered by a fibrin net and clots form.
The muscle fibers of the uterus compress the blood vessels where the placenta
was attached, helping to control bleeding at the placental site.
The uterus continues to contract, forcing the placenta and membranes

to fall into the lower uterine segment (Figure 1-3).
Figure 1-3. Placenta falling into lower uterine segment
With the delivery of the placenta, the uterus is able to

contract completely (Figure 1-4).
Figure 1-4. Empty uterus
Length of third stage of labor

Considerable research has examined how active management affects the third stage of
labor. Investigations found that 50 percent of placental deliveries occur within 5 minutes,
and 90 percent are delivered within 15 minutes.9 Other large studies confirm the rapid
delivery of the placenta; a WHO study found a mean delivery time of 8.3 minutes.9 A third
stage of labor lasting longer that 18 minutes is associated with a significant risk of PPH.10
When the third stage of labor lasts longer than 30 minutes, PPH occurs six times more often
than it does among women whose third stage lasted less than 30 minutes.9
Learning activity 1.1 (Estimated time to complete this

activity: 15 minutes)

Approaches for managing the third stage of labor
There are two main approaches for managing the third stage of labor: the
physiologic (or expectant) approach and the active approach. Table 1-1
compares how the third stage is managed using each of these approaches.
Table 1-1. Comparison of physiologic and active management of the third

stage of labor (AMTSL)
Physiologic (expectant)
Active management*
management
Uterotonic is given within one
Uterotonic is not given before minute of the baby’s birth (after
Uterotonic
the placenta delivered. ruling out the presence of a second
baby).
Wait for signs of separation: Do not wait for signs of
Gush of blood. placental separation. Instead:
Signs of placental Lengthening of cord. Palpate the uterus for a
separation Uterus becomes rounder and contraction.
smaller as the placenta Wait for the uterus to contract.
descends. Apply CCT with countertraction.
Placenta delivered by CCT while
Delivery of the Placenta delivered by gravity
supporting and stabilizing the
placenta assisted by maternal effort.
uterus by applying countertraction.
Massage the uterus after the Massage the uterus after the
Uterine massage
placenta is delivered. placenta is delivered.
Does not interfere with normal
labor process.
Decreases length of third stage.
Does not require special Decrease likelihood of prolonged
drugs/supplies.
third stage.
May be appropriate when Decreases average blood loss.
Advantages immediate care is needed for
the baby (such as
Decreases the number of PPH
cases.
resuscitation) and no trained
assistant is available.
Decreases need for blood
transfusion.
May not require a birth
attendant with injection skills.
Length of third stage is longer

Requires uterotonic and items
needed for injection/injection
compared to AMTSL.
safety.
Disadvantages Blood loss is greater compared
to AMTSL.
Requires a birth attendant with
experience and skills giving
Increased risk of PPH.
injections and using CCT.
*This definition differs from the original research protocol in the Bristol and Hinchingbrooke trials because the
original protocols included immediate cord clamping and did not include massage of the uterus.3,4In the
Hinchingbrooke trial, midwives used either CCT or maternal effort to deliver the placenta.
CCT: controlled cord traction

PPH: postpartum hemorrhage

Scientific evidence supporting use of AMTSL

Giving a uterotonic drug to prevent PPH promotes strong uterine contractions and leads to
faster retraction and placental separation and delivery. Several large, randomized controlled
trials have investigated whether physiologic management or active management is more
effective in preventing PPH. These trials have consistently shown that active management
provides several benefits for the mother compared to physiologic management. Table 1-2
provides detailed results from two important studies, the Bristol3 and Hinchingbrooke4
studies, comparing active and physiologic management of the third stage of labor.
These results show that only 12 women need to receive AMTSL to prevent one case of PPH.
This means that AMTSL is a very effective and cost-efficient public health intervention.
These studies also confirm that AMTSL decreases:
Incidence of PPH.
Length of third stage of labor.
Percentage of third stages of labor lasting longer than 30 minutes.
Need for blood transfusion.
Need for uterotonic drugs to manage PPH.
Table 1-2. Bristol and Hinchingbrooke study results comparing active and
physiologic management of the third stage of labor
Management
Factors Study
Active Physiologic
Bristol 5.9% 17.9 %
PPH
Hinchingbrooke 6.8 % 16.5%
Average length of the third stage Bristol 5 minutes 15 minutes

of labor Hinchingbrooke 8 minutes 15 minutes
Third stage of labor longer than Bristol 2.9% 26%

30 minutes Hinchingbrooke 3.3% 16.4%
Bristol 2.1% 5.6%
Blood transfusion needed
Hinchingbrooke 0.5% 2.6%
Additional uterotonic drugs Bristol 6.4% 29.7%

needed to manage PPH Hinchingbrooke 3.2% 21.1%


Summary
You have just reviewed two ways to manage the third stage of labor—by active
management of physiologic management. During your reading, you should have reflected
on the advantages and disadvantages of each way of managing the third stage of labor, and
reviewed scientific evidence supporting the use of active management of the third stage of
labor. By now you should be convinced that you can improve maternal outcomes and care
by offering active management of the third stage of labor to all women who are giving birth
vaginally.
Because AMTSL can effectively prevent PPH, all birth attendants need to have the
knowledge and ability to apply this valuable skill with competence and confidence. If all
birth attendants are offering AMTSL to all women, this will greatly reduce maternal
morbidity and mortality. You can make a big difference in the fight to save women’s lives
when they give birth.
Review how the third stage of labor is managed in your facility: do most providers apply
active management of the third stage of labor? If not, why don’t they? Think of ways to
make sure that all women who give birth in your facility can have access to AMTSL.
Congratulations!
You have successfully completed the core topic reviewing active management of the third
stage of labor and the evidence for using AMTSL. Write down any questions you have for
your mentor, relax a bit, and then begin core topic 2: PPH causes and prevention.

Core Topic 2: Prevention of postpartum

hemorrhage
Adapted from: PATH. OUTLOOK Volume 19, No 3, May 200211
Overview
Preventing postpartum hemorrhage (PPPH) will reduce the number of women who die or
suffer each year due to excessive bleeding related to pregnancy. It is possible to prevent a
majority of PPH cases. Topic 2 provides an overview of PPH, its causes, and actions that
women, families, and health care providers can take to prevent PPH.
Learning objectives
By the end of this topic, participants will have the tools and knowledge to:
• Define PPH.
• Describe factors that contribute to PPH.
• Describe the causes of PPH.
• Explain ways to prevent PPH.
• Explain ways to ensure timely diagnosis and management of PPH
when it occurs.
Key definitions
Immediate (primary) PPH: Vaginal bleeding in excess of 500 mL, occurring less
than 24 hours after childbirth.
Delayed (secondary) PPH: Excessive vaginal bleeding (vaginal bleeding increases
rather than decreases after delivery), occurring more than 24 hours after childbirth.
Uterine rupture: A tear in the wall of the uterus. In a complete rupture, the tear goes
through all layers of the uterine wall, and the consequences can be dire for mother and
baby. In an incomplete rupture, the peritoneum is still intact. A uterine rupture is a life-
threatening event for mother and baby. A uterine rupture typically occurs during early labor,
but may develop during late pregnancy.
Uterine inversion: A turning of the uterus inside out, whereby the uterine fundus is forced
through the cervix and protrudes into or outside of the vagina.
Disseminated intravascular coagulopathy (DIC): A pathological process in the body
where the blood starts to coagulate throughout the whole body. This depletes the body of
its platelets and coagulation factors, and there is an increased risk of hemorrhage.

Introduction
The loss of some blood during childbirth and postpartum is normal and cannot
be avoided. However, losing any amount of blood beyond normal limits can
cause serious problems even for a woman with normal hemoglobin levels.
Note: The importance of a given volume of blood loss varies

with the woman’s health status.
A woman with a normal haemoglobin level may tolerate
blood loss that would be fatal for an anaemic woman.
—WHO 200712
For many anemic women, even a normal amount of blood loss could be catastrophic.
Fortunately, providers can take action to prevent unnecessary blood loss.
PPH is defined as vaginal bleeding in excess of 500 mL; severe PPH is blood loss exceeding
1,000 mL. Research shows that because it is difficult to measure blood loss accurately, it is
frequently underestimated. For instance, nearly half of women who deliver vaginally often
lose at least 500 mL of blood, and those who give birth by cesarean delivery normally lose
1,000 mL or more. For many women, this amount of blood loss does not lead to problems;
however, outcomes are different for each woman.
For severely anemic women, blood loss of as little as 200 to 250 mL can be fatal. This is
especially important for women living in developing countries, where significant numbers of
women have severe anemia. For these reasons, a more accurate definition of PPH might be
any amount of bleeding that causes a change for the worse in the woman’s condition (e.g.,
low systolic blood pressure, rapid pulse, signs of shock).
Predicting who will have PPH based on risk factors is difficult because two-thirds of
women who have PPH have no risk factors.13 Therefore, all women are considered at
risk, and hemorrhage prevention must be incorporated into care provided at every birth.
Note: Every woman is at risk for PPH.
Causes of PPH
There are several possible reasons for severe bleeding during and after the third stage of
labor. The most important causes of PPH include:
Uterine atony, or inadequate uterine contraction, is the most common cause of severe
PPH in the first 24 hours after childbirth. Contractions of the uterine muscle fibers help
to compress maternal blood vessels. Bleeding may continue from the placental site if
contractions are not adequate.
Cervical, vaginal, or perineal lacerations and episiotomy. Undetected or untreated
lacerations are the second most common cause of PPH. Episiotomy causes loss of blood
and can lead to lacerations. Lacerations can also be caused by deliveries that are poorly
controlled, difficult, or managed with instruments (e.g., large baby, twins, or non-
cephalic presentation). When the woman has genital lacerations, it is still important to
check for and treat uterine atony because these conditions may occur together.
Retained placenta or placental fragments. If the uterus is not empty, it cannot
contract adequately. This can occur if even a small part of the placenta or membranes is
retained. A partially separated placenta may also cause bleeding.

Uterine rupture and uterine inversion. Although rare, these conditions also cause
PPH.
DIC. Although uncommon, this clotting disorder—associated with pre-eclampsia,
eclampsia, prolonged labor, abruption placentae, and infections—is a significant and
serious cause of PPH.
Preventing PPH and careful monitoring during the first hours after birth to ensure timely
detection and management of PPH are critical for every woman at every birth. Despite the
best strategies to prevent blood loss, a small minority of women will still lose blood in
excess of 1,000 mL. Preparing for early treatment of PPH (e.g., additional uterotonic drugs)
is critical to women’s health and survival.

Factors contributing to uterine atony

Uterine atony causes PPH because the uterine muscles are neither
contracting nor retracting. Uterine contractions are essential for closing up
maternal vessels where the placenta separated from the uterine wall.
Blood can continue flowing from the placental site if the uterus does not
contract adequately.
Many factors can contribute to the loss of uterine muscle tone, including:
• Full bladder: If the bladder is full, this may prevent the uterus from contracting
adequately.
• Retained placenta or placental fragments: The placenta may be partially or
completely retained. In either case, the uterus cannot contract adequately when it is
not empty.
• Precipitous labor: When a woman’s labor is less than six hours, her uterus will have
worked extremely hard even if for a short time. When this happens, the uterus can
sometimes be tired and be slower to contract and retract, resulting in uterine atony.
• Prolonged or obstructed labor: When a woman’s labor is too long, her uterus will
have worked hard for a long time. When this happens, the uterus can sometimes be
tired and be slower to contract and retract, resulting in uterine atony.
• Overdistention of the uterus due to multiple gestation, excess amniotic fluid,
large baby, or multiparity: The uterine muscle may become too tired after having
been overdistended for whatever reason, making it slower to contract and retract,
resulting in uterine atony.
• Augmentation of labor: Whenever a woman’s labor requires uterotonic drugs to
stimulate contractions, this means that the uterus is not contracting adequately. If her

labor was augmented with a uterotonic drug, the woman’s uterus may be tired after
childbirth and consequently will not contract well enough to prevent PPH.
Induction of labor: As above, if the uterus is exposed to a uterotonic drug during
labor, it may be too tired after childbirth to contract adequately and result in uterine
atony.

PPH prevention and early detection

It is impossible to predict which women are more likely to have PPH.
However, many factors may contribute to uterine atony or lacerations.
Addressing these factors may help prevent PPH and reduce the amount of
bleeding a woman may have. Taking a preventive approach can save
women’s lives.
Despite the best efforts of health providers, women may still suffer from
PPH. If PPH does occur, positive outcomes depend on how healthy the woman is when she
has PPH (particularly her hemoglobin level), how soon a diagnosis is made, and how quickly
effective treatment is provided after PPH begins.
To prevent PPH and reduce the risk of death, routine preventive actions should be offered to
all women from pregnancy through the immediate postpartum period.
During antenatal care

Health care providers should take the following steps during antenatal care:
Develop a birth preparedness plan. Women should plan to give birth with a skilled
attendant who can provide interventions to prevent PPH (including AMTSL), and can
identify and manage PPH, and refer the woman for additional treatment if
needed.
Develop a complication-readiness plan that includes recognition of danger signs and
what to do if they occur, where to get help and how to get there, and how to save
money for transport and emergency care. For more information, see Additional Topic 2:
Birth preparedness and complication readiness.
Routinely screen to prevent and treat anemia during pre-conceptual, antenatal, and
postpartum visits. Counsel women on nutrition, focusing on available iron- and folic
acid-rich foods, and provide iron/folate supplementation during pregnancy.
Help prevent anemia by addressing major causes, such as malaria and hookworm:
− For malaria, encourage use of insecticide-treated bednets, provide
intermittent preventive treatment during pregnancy to prevent
asymptomatic infections among pregnant women living in areas of
moderate or high transmission of Plasmodium falciparum, and ensure
effective case management for malaria illness and anemia.
− For hookworm, provide treatment at least once after the first trimester.

In cases where the woman cannot give birth with a skilled attendant, prevent
prolonged/obstructed labor by providing information about the signs of labor, when labor
is too long, and when to come to the facility or contact the birth attendant.
Prevent harmful practices by helping women and their families to recognize harmful
customs practiced during labor (e.g., providing herbal remedies to increase contractions,
health workers giving oxytocin by intramuscular [IM] injection during labor).
Take culturally sensitive actions to involve men and encourage understanding about the
urgency of labor and need for immediate assistance.
During labor and second stage

Health care providers should take the following steps during the first and second stages of
labor:
Use a partograph to monitor and guide management of labor and quickly detect
unsatisfactory progress.
Ensure early referral when progress of labor is unsatisfactory.
Encourage the woman to keep her bladder empty.
Limit induction or augmentation use for medical and obstetric reasons.
Limit induction or augmentation of labor to facilities equipped to perform a cesarean
delivery.
Do not encourage pushing before the cervix is fully dilated.
Do not use fundal pressure to assist the birth of the baby.
Do not perform routine episiotomy. Consider episiotomy only with complicated vaginal
delivery (e.g., breech, shoulder dystocia, forceps, vacuum, scarring from female genital
cutting or poorly healed third- or fourth-degree tears, and fetal distress).
Assist the woman in the controlled delivery of the baby’s head and shoulders to help
prevent tears. Place the fingers of one hand against the baby’s head to keep it flexed
(bent), support the perineum, and instruct the woman to use breathing techniques to
push or stop pushing.
During third stage

Health care providers should take the following steps during the third stage:
Provide AMTSL—the single most effective way to prevent PPH.
Do not use fundal pressure (apply pressure on a woman's abdomen to help expel the
placenta) to assist the delivery of the placenta.
Do not perform CCT without administering a uterotonic drug.
Do not perform CCT without providing countertraction to support the uterus.
Do not perform CCT if you have not been trained and/or are not competent to do so.

After delivery of the placenta
Health care providers should provide the following care during the immediate postpartum
period (the first six hours after childbirth):
Routinely inspect the vulva, vagina, perineum, and anus to identify genital lacerations.
Cervical examination is only recommended when the cause of PPH has not been
diagnosed and uterine atony, lower genital lacerations, and retained placenta are ruled
out.
Inspect the placenta and membranes.
Evaluate if the uterus is well-contracted and massage the uterus at regular intervals
after placental delivery to keep the uterus well-contracted and firm (at least every 15
minutes for the first two hours after birth).
Teach the woman to massage her own uterus to keep it firm. Instruct her on how to
check her uterus and to call for assistance if her uterus is soft or if she experiences
increased vaginal bleeding.
Monitor the woman for vaginal bleeding and uterine hardness every 15 minutes for the
first two hours, every 30 minutes during the third hour, and then every 60 minutes for
the next three hours.
Encourage the woman to keep her bladder empty during the immediate postpartum
period.
Plan to do a complete assessment of the woman one and six hours after childbirth.
Teach the woman and her family about postpartum and newborn danger signs. Help the
family develop a complication-readiness plan before the woman is discharged from the
health care facility.


Summary
You have just reviewed the major causes of PPH and ways to prevent it. During your
reading, you should have reflected on the strategies discussed to prevent PPH and to make
sure you identify and treat PPH in a timely manner. Review how care is provided in your
facility and decide which of the following strategies are already being carried out in your
facility:
Developing a birth-preparedness plan during antenatal care visits.
Developing a complication-readiness plan during antenatal and postpartum care
visits.
Screening for, treating, and preventing anemia during pregnancy.
Monitoring labor using the partogram.
Encouraging the woman to keep her bladder empty during the first and second
stages of labor and in the immediate postpartum period.
Augmenting or inducing labor only when there are strict obstetric or medical
reasons for it.
Applying AMTSL for all vaginal births.
Carefully examining the woman’s external genitalia and placenta after birth.
Monitoring the woman and newborn closely during the first 6 hours after
childbirth.
If some of these strategies are not being carried out in your facility, analyze why they are
not and discuss with your colleagues and manager ways to make sure that each woman
who comes into your facility can benefit from simple strategies to prevent PPH.
Congratulations!
You have successfully completed the core topic reviewing the causes and prevention of PPH.
Write down any questions you have for your mentor, relax a bit, and then begin core topic
3a: Review of uterotonic drugs.
.

Core Topic 3a: Review of uterotonic drugs
Overview
Administering a uterotonic drug immediately after birth of the baby and before delivery of
the placenta is one of the most important ways to prevent PPH. The most common
uterotonic drug—oxytocin—is extremely effective in both reducing the incidence of PPH and
shortening the third stage of labor. Oxytocin is the drug of choice for AMTSL, and is more
heat- and light-tolerant (stable) than ergometrine. This topic will review and compare the
drugs used to stimulate uterine contractions during the third stage of labor and review the
stability, storage requirements, and costs of uterotonic drugs.
Learning objectives
• Identify uterotonic drugs used in the third stage of labor.
• List dangers of improper use of uterotonic drugs during the third
stage of labor.
• Describe the dosage, route, drug action, effectiveness, side effects,
and cautions for uterotonic drugs used for AMTSL.
Key definitions
Tonic or tetanic contractions: Continuous contractions with no relaxation.
Uterotonics: Substances that stimulate uterine contractions or increase uterine
tone. Uterotonics include:
Oxytocin (the most commonly used uterotonic drug): Oxytocin is
secreted naturally by the posterior pituitary during later pregnancy, labor,
and when the baby breastfeeds. Synthetic forms of oxytocin can be found
in products such as Pitocin® and Syntocinon®. In moderate doses,
oxytocin produces slow, generalized contractions of the muscles of the
uterus with full relaxation in between. High doses of oxytocin produce
sustained tonic contractions that can be dangerous.
Ergot-based compounds (another class of uterotonic drugs):
Methergine® (methylergonovine maleate) and ergometrine (ergometrine
maleate) are the ergot preparations used today. They cause tetanic
(continuous) contractions of the uterus and may cause or exacerbate high
blood pressure.
Syntometrine (a combination of oxytocin and ergometrine maleate):
Syntometrine has both the fast-acting quality of oxytocin and the tetanic
contraction action of ergometrine.

Prostaglandins (naturally occurring fatty acids found in the uterus,
menstrual fluids, and amniotic fluid): Misoprostol, an E1 analog
prostaglandin, is used for a range of obstetric and gynecologic purposes
such as cervical ripening, induction of labor, prevention and treatment of
PPH, and post-abortion care.
Use of uterotonics
Uterotonics act directly on the smooth muscle of the uterus and increase the
tone, rate, and strength of rhythmic contractions. The body produces a
natural uterotonic—the hormone oxytocin—that acts to stimulate uterine
contractions at the start of labor and throughout the birth process.
Drugs such as oxytocin, ergometrine, and misoprostol have strong uterotonic properties and
are used to treat uterine atony and reduce the amount of blood lost after childbirth.
Oxytocin is widely used for induction and augmentation of labor. The use of a uterotonic
drug immediately after the delivery of the newborn is one of the most important actions
used to prevent PPH.
Improper use of uterotonic drugs

Uterotonic drugs (oxytocin or misoprostol) are sometimes used to induce or augment
labor. When labor is augmented with a uterotonic drug, the quality and quantity of uterine
contractions are greatly affected. The contractions tend to be longer and stronger, and have
shorter relaxation periods between each. While augmentation with uterotonic drugs plays a
major role in managing unsatisfactory progress of labor due to inadequate or ineffective
uterine contractions, improper use of uterotonics results in grave risks for the
woman, including:
Umbilical cord compression and subsequent decrease in the baby's oxygen supply
(occurs with the increased pressure of contractions).
Uterine rupture and abruptio placentae.
Increased pain of the uterotonic-induced contractions, which will likely increase the
woman’s stress and anxiety levels.
Water intoxication that results when oxytocin—a strong anti-diuretic, even at low
doses—is combined with intravenous (IV) fluids.
Uterine fatigue after childbirth (associated with uterine atony and PPH).
Before deciding to augment labor, the provider should carefully assess the woman and fetus
and evaluate the partograph. Labor should be augmented only if:
Clear emergency or obstetric conditions are present, and
Health care personnel familiar with the effects of uterotonics and able to identify
both maternal and fetal complications are present, and
A physician is readily available to perform a cesarean delivery should complications
arise.
Never administer oxytocin intramuscularly (IM) during labor. If
oxytocin is used for labor augmentation, it should be administered by
controlled IV drip in a health facility that has an operating theater and
qualified physician to perform an emergency caesarean operation.
Always follow local guidelines or protocols for uterotonic drug dosages
for labor induction and augmentation.

When 25 mcg tablets of misoprostol are not available, do not

break higher dose tablets (usually 200 mcg) and administer for
induction or augmentation. When 200 mcg tablets are broken, the
exact dose of misoprostol being give to the woman is not reliable and
could be dangerous. If more than 25 mcg of misoprostol is
administered during labor, this could cause a uterine rupture and/or
the death of the baby.
.
Learning activity 3.1(Estimated time to complete this

Uterotonic drugs used for AMTSL
Table 3-1 compares dosage, route of administration, drug action and
effectiveness, side effects, and cautions for the most common uterotonic drugs
used for AMTSL. Remember that oxytocin is the uterotonic drug of choice for
AMTSL.
Table 3-1. Uterotonic drugs for AMTSL
Name of Dosage and Drug action and Side effects and cautions
drug/preparation route effectiveness
Oxytocin
Posterior pituitary Acts within 2–3 First choice.
Give 10 units
extract. Commonly
IM injection.*
minutes. No known contraindications for
used brand names Effect lasts about postpartum use.**
include Pitocin or 15–30 minutes. Minimal or no side effects.
Syntocinon.
Orally:
Misoprostol Synthetic Acts within 3–5
prostaglandin E1 (PGE1) Give 600 mcg minutes
No known contraindications for
analogue. Commonly (three 200 Peak serum postpartum use.**
used brand names mcg tablets) concentration
include Cytotec, orally. between 18–34
Common side effects: shivering
Gymiso, Prostokos, and elevated temperature.
minutes
Vagiprost, U-Miso Effect lasts 75
minutes
Contraindicated in women with a
Ergometrine history of hypertension, heart
(methylergometrine), disease, retained placenta, pre-
also known as eclampsia, or eclampsia.***
ergonovine Causes tonic contractions (may
(methylergonovine) Acts within 6–7 increase risk of retained
Preparation of ergot Give 0.2 mg minutes IM. placenta).
(usually comes in dark IM injection. Effect lasts 2–4 Side effects: nausea, vomiting,
brown ampoule). hours. headaches, and hypertension.
Commonly used brand
names include Note: Do not use if drug is cloudy.
Methergine, Ergotrate, This means it has been exposed to
Ergotrate Maleate excessive heat or light and is no
longer effective.
Syntometrine Combined rapid

Same cautions and
contraindications as
Combination of 5 IU Give 1 mL IM action of oxytocin
ergometrine.
oxytocin plus 0.5 mg injection. and sustained action
ergometrine. of ergometrine. Side effects: nausea, vomiting,
headaches, and hypertension.
*
If a woman has an IV, an option may be to give her 5 IU of oxytocin by slow IV push.
**
This is intended as a guide for using these uterotonic drugs during the third stage of labor. Different guidelines
apply when using these uterotonic drugs at other times or for other reasons.
***
Lists of contraindications are not meant to be complete; evaluate each client for sensitivities and appropriateness
before use of any uterotonic drug. Only some of the major postpartum contraindications are listed for the above
drugs.
IM: intramuscular; IV: intravenous

Comparison of uterotonic drugs for AMTSL

Oxytocin is fast-acting, inexpensive, and in most cases, has no side effects or
contraindications for use during the third stage of labor. Oxytocin is also more stable than
ergometrine in hot climates and light (when cold/dark storage is not possible). WHO
recommends oxytocin as the drug of choice for AMTSL and advises that ergometrine,
Syntometrine, or misoprostol be used only when oxytocin is not available.
WHO recommends oxytocin as the drug of choice for

AMTSL.
Misoprostol is a synthetic prostaglandin E1 (PGE1) analogue and is an alternative drug for

AMTSL. Directions on its use for AMTSL are included in the International Federation of
Gynaecology and Obstetrics (FIGO)/International Confederation of Midwives (ICM)
statement, Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low
Resource Settings. Oxytocin is the uterotonic of choice for AMTSL;14 however, safe
administration of an injection requires skills and sterile equipment. Oxytocin may be
inactivated if exposed to high ambient temperatures. 15
Misoprostol is reportedly more stable than oxytocin and has been administered by oral,
sublingual, and rectal routes in several studies. 16 Oral misoprostol is being viewed as an
alternative drug for AMTSL for women delivering in low-resource settings where oxytocin
and a skilled birth attendant may not be available17 and as a PPH treatment when used in
combination with other uterotonics. 18, 19 It has also been suggested that misoprostol
tablets can be used for the prevention of PPH either by non-skilled providers or by women
themselves when oxytocin or a skilled birth attendant are not available.
Oxytocin in the UnijectTM device (Uniject is a registered trademark of BD)—a prefilled, easy-
to-use, non-reusable syringe—is an advance in the
method of delivering oxytocin and is currently being used
in pilot studies (Figure 3-1). This delivery method ensures
the correct dose is given with little preparation and
medical waste. The benefits of this device may improve
the ability of midwives and other health workers to
administer oxytocin outside of hospital facilities, in
emergencies, or in remote locations. Appendix B contains
information on activating and using the Uniject device.
Figure 3-1. The UnijectTM device.

(http://www.path.org/projects/
uniject.php)

Recommendations for selection of a uterotonic

drug for prevention of PPH
In the context of active management of the third stage of labor, if all

injectable uterotonic drugs are available:
• Skilled attendants should offer oxytocin to all women for prevention of PPH in
preference to ergometrine/methylergometrine.
This recommendation places a high value on avoiding adverse effects of ergometrine
and assumes similar benefit for oxytocin and ergometrine for preventing PPH.20
• Skilled attendants should offer oxytocin for prevention of PPH in preference to oral
misoprostol (600 mcg).
This recommendation places a high value on the relative benefits of oxytocin in
preventing blood loss compared to misoprostol, as well as the increased adverse
effects of misoprostol compared to oxytocin.20
In the context of active management of the third stage of labor, if oxytocin is not available,
but other injectable uterotonics are available:
• Skilled attendants should offer ergometrine/methylergometrine or the fixed drug
combination of oxytocin and ergometrine to women without hypertension or heart
disease for prevention of PPH. 20
• Skilled attendants should offer 600 micrograms (mcg) misoprostol orally to women
with hypertension or heart disease for prevention of PPH.
To prevent PPH, if the birth attendants’ skills are limited, oxytocin or misoprostol should be
administered soon after the birth of the baby.21 The usual components of preventing PPH by
administering a uterotonic after birth of the baby include:
• Administration of 600 micrograms (mcg) misoprostol orally or oxytocin10 IU
intramuscularly after the birth of the baby and the presence of another baby has
been ruled out.
• CCT ONLY when a skilled attendant is present at the birth.
• Uterine massage after the delivery of the placenta.


Summary
You have just reviewed the dangers of improper use of uterotonic drugs during labor as well
as the characteristics of uterotonic drugs used for AMTSL. You have learned that oxytocin is
the uterotonic of choice for AMTSL because it begins acting 2 to 3 minutes after injection, it
has very few side effects, and it can be given to all women in the postpartum period.
Your challenge now is to evaluate if uterotonic drugs are used according to standards in
your health care facility. If they are not, talk with your colleagues and managers to find a
way to make sure that uterotonic drugs are not used improperly and to make sure that the
uterotonic drugs recommended for AMTSL are available.
Congratulations!
You have successfully completed the core topic reviewing uterotonic drugs used for AMTSL.
Write down any questions you have for your mentor, relax a bit, and then begin the next
part of core topic 3b: Managing uterotonic drugs.
.

Core Topic 3b: Managing uterotonic drugs

Overview
The availability of uterotonic drugs is essential for the application of AMTSL. Oxytocin is the
uterotonic drug of choice for AMTSL because it acts quickly, has few side effects, can be
offered to all women for AMTSL, and is much more stable than ergometrine when exposed
to heat and light.
You will now review: 1) recommendations for storing uterotonic drugs used for AMTSL, 2)
how to estimate the quantity of uterotonic drugs to order for your facility, and 3) the best
way to manage uterotonic drugs.
Learning objectives
Describe recommendations for storing uterotonic drugs used for AMTSL.
Describe the importance of documenting uterotonic drug use and movement.
Identify problems related to poor documentation of uterotonic drugs.
Estimate the quantity of uterotonic drugs to order for your facility.
Key definitions
Request indicator (RI): The level of drugs in stock; it indicates when fresh orders should
be made. This is also known as the “minimum stock level.”
FIRST IN FIRST OUT (FIFO): The rule to apply when using drugs. Drugs that were
received first should be used first, except where the new stock has shorter expiration dates
than the old stock.
FIRST TO EXPIRE FIRST OUT (FEFO): The rule to apply when using drugs. Drugs that
expire first should be used first.
Average monthly consumption: The average quantity of a drug used over the period of
one month.
Delivery (lead) time: The time it takes to have a drug delivered and receipted in the
store.
Quantity to be requested: The quantity of drug to be ordered. This will depend on the
volume of births at the health centre, the quantity previously consumed, when drugs were
not out of stock, the period for which the new stock is to serve and the estimated number of
births for that period.
Request indicator (RI) (also may be known as “minimum stock level”): The level of
drugs in stock; it indicates when fresh orders should be made. It is the quantity that is
calculated to last between the period of placing the order and the delivery of the new
consignment.
Stock in balance: The quantity of drug remaining in the store, once any expired or broken
vials / ampoules have been subtracted.

Management of uterotonic drugs
Source: WHO Regional Office for Africa. Management of Drugs at Health
Centre Level: Training Manual. Brazzaville, Congo: WHO, 2004.
Two reasons can be given to explain why drugs need to be managed properly. Firstly, drugs
are part of the link between the patient and health services. Consequently, their availability
or absence will contribute to the positive or negative impact on health. Secondly, while poor
drug management is a common problem, major improvements are possible that can save
money and improve access to care.
Each country and each facility has a different system for ordering drugs. The concepts
described here should guide providers in understanding how drugs should be ordered as
well as in evaluating the system that is currently being used in their facility.
General rules
(1) Managing uterotonic drugs requires: 1) coordination between personnel in the
pharmacy and personnel caring for women during labor and childbirth, 2) careful
documentation of use, and 3) careful documentation of flow. Proper management
requires that the following tools be used correctly and by all personnel who come in
contact with uterotonic drugs :
- Bin (stock) cards in the storeroom, pharmacy, and delivery room,

- Daily use record, daily cash record,
- Delivery logbook,
- Drug register.
- Procurement / delivery records.
(2) Clearly identify and document any ampoules that are expired or have been broken. If
an ampoule has expired or broken:
• Do not keep it with stock to be distributed / used.
• Put all broken or expired ampoules in a closed safety box that is clearly labeled
“Expired, do not use.”
• Store the safety box at a safe distance from stock to be distributed / used.
• Subtract any expired or broken ampoules from the “balance in stock” as soon as
they are taken out of the stock to be distributed / used.
• Apply national protocols for destruction or return of expired or broken ampoules.
(3) Always apply the rule of FIRST IN FIRST OUT (FIFO). Drugs that were received
first should be used first, except where the new stock has shorter expiration dates than
the old stock.
(4) Apply the rule of FIRST TO EXPIRE FIRST OUT (FEFO). To have access to drugs
with shorter expiration dates first, put these in front of the shelves. Those with longer
expiration dates should be placed behind those with shorter dates.
(5) Movement of uterotonic drugs should always be documented in at least two different
management tools to guarantee accurate information and accountability. For example:
• Movement of uterotonic drugs should be documented on the stock card when
uterotonic drugs are dispensed from the pharmacy for use in the delivery room.

Example 1: The stock card at the dispensing point (pharmacy):
• Movement of uterotonic drugs should be documented in the log book in the delivery
room when uterotonic drugs are dispensed from the pharmacy for use in the delivery
room.
Example 2: Oxytocin log book
• When a uterotonic drug is administered in the delivery room, it should be

documented in the log book in the delivery room and the delivery log book:
- The uterotonic drug log book in the delivery room (see example 2)
- The delivery log book (on the same line as the client who received the uterotonic
drug):

Example 3: Delivery log book
Document movement of uterotonic drugs in at least

two different management tools to guarantee
accurate information and accountability.
Procurement
The estimate of the drug and dosage forms required for a given period is undertaken:
• To avoid shortages (out of stock) and ensure credible health care service,
• To prevent excess stock and avoid waste (loss or mismanagement of financial
resources).
Factors that influence choice and quantity of drugs include:
• Population which the health institution serves,
• Volume of birth,
• Seasonal variation in number of births to be expected,
• Monthly (rate of) drug consumption,
• Delivery (lead) time,
• Time lag between placing orders and receiving the orders,
• Request indicator (re-order level):
• Quantity of drug product that serves as a signal for re-ordering.
The maximum quantity of drugs held in stock is determined by:
• Distance from the central health services area or regional medical store,
• Size of the health centre store,
• Number of women giving birth at the health centre.
In this section, four factors-delivery (lead) time, stock left, monthly consumption and
request indicator-are considered as the basis for calculating the appropriate quantity of a
particular drug to be ordered.

Delivery (lead) time

It is important to establish how long it takes to have a drug delivered and receipted in the
store so that the drug does not become out of stock. This period is called the delivery or
lead time. Delivery time may be days, weeks or even months. Delivery time may be longer
than two months because of the following reasons:
• Poor road conditions, particularly in the rainy season,
• Poor condition of delivery vehicles,
• Increased work load at the issuing store,
• Non-availability of adequate resources at the central store,
• Consumption rate of drugs.
Stock in balance
Stock refers to the number of medications available for use at the health facility, after
subtracting any stock that has expired or broken. The amount of stock available can be
calculated using bin (stock) cards in the pharmacy and delivery room, daily use cards, and
cash cards.
Example: count of oxytocin 10 IU ampoules in a health centre:
Store room: 10 ampoules of oxytocin 10 IU ampoules (2 expired)
Pharmacy: 6 ampoules of oxytocin 10 IU ampoules
Delivery room: 8 ampoules of oxytocin 10 IU ampoules (1 expired)
Stock left: (10-2) + 6 + (8-1) = 21 ampoules
Monthly consumption
Monthly consumption may be collated with data obtained from:
• Bin (stock) cards,
• Daily use record, daily cash record,
• Delivery logbook,
• Drug register.
Normally, monthly consumption is obtained by:
• Calculating the average consumption over a period of time (e.g. six months)
• Or dividing the total consumption over the period by the number of months the drug
was consumed.
Example 1: Monthly consumption
The first method of calculating monthly consumption is to add the quantity of drugs in stock
at the beginning of a period (e.g., six months) to the quantity of drugs received during that
same period and then subtract the quantity of drugs remaining at the end of the period.
April 2008, quantity of oxytocin 10 IU ampoules in stock = 140
June 2008, quantity of oxytocin 10 IU ampoules received = 80
September 2008, quantity of oxytocin 10 IU ampoules, remaining stock = 60
Therefore, total quantity of paracetamol oxytocin 10 IU ampoules consumed over a
six-month period = 140 + 80 - 60 = 160.
Average monthly consumption = 160/6 = 26 oxytocin 10 IU ampoules

A second method of calculating the average monthly consumption is to obtain data on
consumption from the bin card on a monthly basis and then find an average over a period of
time.
April 2008 20 oxytocin 10 IU ampoules
May 2008 40 oxytocin 10 IU ampoules
June 2008 20 oxytocin 10 IU ampoules
July 2008 20 oxytocin 10 IU ampoules
August 2008 30 oxytocin 10 IU ampoules
September 2008 30 oxytocin 10 IU ampoules
160 oxytocin 10 IU ampoules
160 oxytocin 10 IU
Average monthly ampoules 26 oxytocin 10 IU
=
consumption is ampoules
6
A third method of calculating average monthly consumption is to obtain data on actual
consumption from the daily use record or daily use/cash record.
Data of monthly consumption of oxytocin 10 IU ampoules over a six-month period.
April 2008 16 oxytocin 10 IU ampoules
May 2008 36 oxytocin 10 IU ampoules
June 2008 18 oxytocin 10 IU ampoules
July 2008 22 oxytocin 10 IU ampoules
August 2008 28 oxytocin 10 IU ampoules
September 2008 32 oxytocin 10 IU ampoules
Total six months 152 oxytocin 10 IU ampoules
Average monthly consumption of
152/6 = 25 oxytocin 10 IU ampoules
oxytocin 10 IU ampoules is
Example 4: AMTSL is not yet being applied in the facility

If AMTSL is not yet being applied in your facility, you will not be able to base your command
on previous monthly consumption. Instead, estimate the number of births during the time
period and add this to the monthly consumption to calculate average monthly consumption.
Data of monthly consumption of oxytocin 10 IU ampoules over a six-month period
prior to introducing AMTSL.
Month Oxytocin 10 IU ampoules used Vaginal births
April 2008 16 24
May 2008 36 52
June 2008 18 34
July 2008 22 36
August 2008 28 42
September 2008 32 48
Total six months 152 oxytocin 10 IU ampoules 236
Average monthly consumption of
152/6 = 25 oxytocin 10 IU ampoules
oxytocin 10 IU ampoules
Estimated monthly consumption if
(152 + 236) / 6 = 65
AMTSL was applied

In this example, the average monthly consumption of oxytocin 10 IU ampoules was

25 ampoules per month before providers began applying AMTSL. If providers begin
applying AMTSL, there will shortly be a stock-out of oxytocin because consumption
will greatly increase after the introduction of AMTSL to a facility.
For this example, the estimated monthly consumption of 65 ampoules should be
used when calculating the quantity of oxytocin ampoules to order.
Request indicator (re-order)

The request indicator (RI) is the level of drugs in stock that indicates when fresh orders
should be made. It is the quantity that is calculated to last between the period of placing
the order and the delivery of the new consignment. This is also known as the “minimum
stock order.”
The RI is marked with pencil in the space “RI” on the top of the stock card. It should be
updated at least twice a year because consumption may vary due to seasonal changes.
This will ensure that no shortage of stock occurs before the next consignment is expected.
The stock should not be allowed to fall below this level before a new order is placed. Each
stock card must have an RI that is updated from time to time as consumption varies.
The stock should never reach “zero level” before a request is made, as there will be a
shortage of stock for some time. It is easy to calculate the RI once the monthly
consumption is obtained.
If the delivery time is three months and the average monthly consumption is 26,
then the RI is: 26 oxytocin 10 IU ampoules × 3 months = 78 oxytocin 10 IU
ampoules.
This means that when the stock of oxytocin 10 IU ampoules is reduced to 78
ampoules, a new request must be made.
Quantity to be requested
The type and quantity of drug to be ordered will depend on the volume of births at the
health centre, the quantity previously consumed, when drugs were not out of stock, the
period for which the new stock is to serve and the estimated number of births. In
determining the quantity to be requested:
• Consider the lead or delivery time.
• Consider the number of women who will need AMTSL, may need treatment for PPH, and
may need oxytocin for augmentation or induction of labor (using national treatment
guidelines).
• Look through all the stock cards in a systematic manner and compare the RI with the
current stock balances.
• Request only those items where the stock balance approaches the RI, equals the RI or is
below the RI.
• Subtract quantities above the RI from the quantity to be ordered; Add quantities below
the RI to the quantity to be ordered.
The quantity to be ordered is: [(Average monthly consumption × Lead
time) + (1 month consumption for unforeseen events) +/- (difference
between RI and Stock in balance)

Example 1:
RI = 78 oxytocin 10 IU ampoules; Current stock balance = 80 oxytocin 10 IU ampoules
Delivery (lead) time = 3 months
Average monthly consumption = 78 / 3 = 26 ampoules
Request quantity
Average monthly consumption (26 ampoules) × Lead time (3 months) + 1 month
consumption for unforeseen events (26 ampoules)
= (26 × 3) + 26 = 104 ampoules
In this case the RI is above by 2 ampoules.
Therefore, make the normal request less by 2 ampoules: 78-80 = (-)2
Quantity to order = 104 ampoules – 2 ampoules = 102 ampoules.
Example 2:
RI = 96 oxytocin 10 IU ampoules; current stock balance = 96 oxytocin 10 IU ampoules
Average monthly consumption is: 96 ampoules / 3 months = 32 ampoules
Request quantity
= (32 × 3) + 32 = 128 ampoules
In this case the RI is the same as the stock in hand: 96-96 = 0.
Therefore, the request will be:
Quantity to order = (32 × 3) + 32 = 128 ampoules.
Example 3:
RI = 126 oxytocin 10 IU ampoules; current stock balance = 98 oxytocin 10 IU ampoules
Average monthly consumption is: 126 ampoules / 3 months = 42 ampoules
Request quantity
= (42 × 3) + 42 = 168 ampoules
In this case the stock in balance (98 ampoules) is quite a bit less than the RI (126
ampoules) and an extra quantity must be requested to cover the RI.
Therefore, make the normal request plus an additional 28 ampoules: 126-98 = (+)28
Quantity to order = (42 x 3) + (42) + (28) = 196 ampoules
Example 4: AMTSL is not yet being applied in the facility
Average estimated monthly consumption (actual consumption + number of vaginal
births) is: 65
RI = 65 x 3 = 195 oxytocin 10 IU ampoules; current stock balance = 76 oxytocin 10 IU
ampoules
In this case an extra quantity must be requested to cover the RI (195-76=119).
Request quantity = Average estimated monthly consumption (65 ampoules) × Lead
time (3 months) + 1 month consumption for unforeseen events (65 ampoules)
= (65 × 3) + 65 = 260 ampoules + (195-76) = 379 ampoules

In each case above, if previous data show that the number of patients would increase (e.g.
delivery cases due to seasonal variations), then the quantities should be increased
proportionally. If the number of deliveries is expected to double, then the quantity should
be multiplied by 2. If the number of deliveries is expected to drop by half, then the quantity
should be multiplied by 1/2.
Oxytocin is unique because it can be used for several different purposes – prevention of
PPH, treatment of PPH, augmentation of labor, induction of labor, treatment of incomplete
abortion, etc. All of these different uses of oxytocin need to be considered when looking at
monthly consumption and anticipating need.
Drug request
It is advisable to request drugs on a regular basis to prevent shortages. If drugs are not
always available, patients may lose confidence in the health centre and will be discouraged
from visiting it. It is important to make requests on a regular basis, as drugs will only be
delivered when requested. The delivery time should be taken into consideration in ensuring
that drugs are not in short supply.
We don’t have Hm….maybe that’s because she

any more doesn’t want to be bothered with
oxytocin. managing our drugs.
Figure 3-2. Importance of quantifying and

ordering drugs regularly (Gomez, 2005)

Keeping uterotonic drugs effective
The stability of a drug is defined by how well it maintains active ingredient

potency (and other measures such as pH) when stored over time.
Pharmaceutical companies conduct stability studies to determine the
appropriate shelf-life, storage conditions, and expiration dating for safe storage of the
oxytocin they produce. A manufacturer will recommend storage conditions based on the
conditions under which he has performed stability studies, and will set the expiry date to be
consistent with this. It is therefore important to read storage recommendations made by
the manufacturer.
Since ergometrine and Syntometrine are sensitive to heat and light, and oxytocin is
sensitive to heat, following storage guidelines is critical to ensure the optimal effectiveness
of injectable uterotonic drugs. When drugs are inadequately stored, drug effectiveness can
diminish, posing serious consequences for the postpartum woman.
Storage practices in health care facilities vary widely and may not follow guidelines for
correct storage. For example, vials of uterotonic drugs might be kept on open trays or
containers in the labor ward, leaving them exposed to heat and light. Pharmacists,
pharmacy managers, and birth attendants using the oxytocin need to carefully read and
follow recommended guidelines for transporting and storing uterotonic drugs.
Recommended guidelines for transporting and storing specific uterotonic drugs are noted in
Table 3-2.
Table 3-2. Recommended guidelines for transport and storage of
uterotonic drugs
Drug Transport Storage
Check manufacturer’s
recommendations – some
manufacturers are producing
oxytocin that is more heat stable
Unrefrigerated transport is
than previously available
possible if no more than one
Oxytocin Temporary storage outside the
month at 30°C or two weeks at
refrigerator at a maximum of 30°C
40°C.
is acceptable for no more than three
months.
If possible, keep refrigerated at 2–
8°C.
Store at room temperature in closed
Misoprostol Protect from humidity. container and protected from
humidity.

Drug Transport Storage

Unrefrigerated transport in the
Store in the dark.
dark is possible if no more than
Keep refrigerated at 2–8°C.
Syntometrine one month at 30°C C or two
weeks at 40°C. Protect from
Store in closed container.
freezing. Protect from freezing.
Unrefrigerated transport in the
Store in the dark.
dark is possible if no more than
Keep refrigerated at 2–8°C.
Ergometrine one month at 30°C C or two
weeks at 40°C. Protect from
Store in closed container.
freezing. Protect from freezing.
Effect of heat and light on uterotonic drugs

Two factors can influence the effectiveness of uterotonic drugs: temperature and light. This
is especially important in hot temperatures and in conditions where refrigeration is not
always available or reliable. A WHO research program examined the effectiveness of
different injectable uterotonic drugs at various temperatures and light conditions15. Table 3-
3 shows one comparison from this study.
Table 3-3. Change in effectiveness of injectable uterotonic drugs after one
year of controlled storage
Dark Dark Light Effects of heat and
Uterotonic drug º º º
4-8 C 30 C 21-25 C light/key findings
Minimal effect from light,

more stable for longer time
Oxytocin 0% loss 14% loss 7% loss
at higher temperatures
than ergometrine
Significantly more affected

by heat and light, not
Ergometrine 5% loss 31% loss 90% loss
stable at higher
temperatures
Tips to increase uterotonic drug effectiveness

In the pharmacy:
Make sure that there are adequate stocks of uterotonic drugs, syringes, and injection
safety materials
Check the manufacturer’s label for storage recommendations
Make sure that there is a system in place to monitor the temperature of the
refrigerator / cold box - record the temperature in the refrigerator on a regular
basis, preferably at the hottest times of the day (put thermometers in different parts
of the refrigerator)
Make sure that there is a back-up system in place in case of frequent electricity cuts
- for example, gas or solar refrigerators, placing ice packs in the refrigerator to keep
it cool, etc.

Follow the rule of first expired – first out (or first in – first out) and maintain a log to
keep track of expiration dates to reduce wastage of uterotonic drugs
Store misoprostol at room temperature and away from excess heat and moisture
To ensure the longest life possible of injectable uterotonics, keep them
refrigerated at 2–8°C
Protect ergometrine and Syntometrine from freezing and light.
In the delivery room:
Check the manufacturer’s label for recommendations on how to store injectable

uterotonic drugs outside the refrigerator. In general:
- Oxytocin may be kept outside the refrigerator at a maximum of 30°C (warm,
ambient climate) for up to three months and then discarded
- Ergometrine and Syntometrine vials may be kept outside the refrigerator in
closed boxes and protected from the light for up to one month at 30°C and then
discarded
- Misoprostol should be stored at room temperature away from excess heat and
moisture
Record the temperature in the delivery room on a regular basis, preferably at the
hottest times of the day
Periodically remove ampoules from the refrigerator for use in the delivery room –
carefully calculate the number removed from the refrigerator based anticipated need
Only remove ampoules or vials from their box just before using them
Make sure that there are adequate stocks of syringes and injection safety materials
Avoid keeping injectable uterotonics in open kidney dishes, trays, or coat pockets
Ergometrine loses 21–27 percent potency in one month of

exposure to indirect sunlight.
Oxytocin has no loss of potency after one month exposure to
indirect sunlight.


Time temperature indicators

Vaccine vial monitors (VVMs)* are small stickers that adhere to a vaccine
vial and change color as the vaccine is exposed to heat. The color of the
sticker indicates whether a vaccine or medication is bad or can be safely
used. In 1996, the first monitors became commercially available for oral
polio vaccine. Today, monitors are available for all vaccines used in
immunization programs in developing countries.
Oxytocin in the Uniject™ device is the first uterotonic drug to use VVM technology, where
the label contains heat-sensitive material and indicates heat exposure over time. As the
device is exposed to warm temperatures, the time-temperature indicator (TTI) color
darkens (Figure 3-3). The warmer the temperature, the faster the color changes on the TTI.
Figure 3-3. Reading the time-temperature indicator
The inner square is lighter than the outer circle. If the expiry date has not
passed, use the oxytocin-Uniject.
As time passes the inner square is still lighter than the outer circle. If the
expiration date has not passed, use the oxytocin-Uniject.
Discard point: the color of the inner square matches that of the outer
circle. Do not use the oxytocin in Uniject even if the expiration date has
not passed.
Discard point: the inner square is darker than the outside circle. Do not
use the oxytocin in Uniject even if the expiration date has not passed.

* The VVM concept was developed in 1979 by WHO and PATH, with funding from the United States
Agency for International Development. Temptime Corporation (formerly Lifelines Inc.) today provides
VVMs to all vaccine manufacturers.

Summary
You have just reviewed how to calculate the quantity of uterotonic drugs you will need for
your health facility and how to store them to ensure their effectiveness. Proactive
management of uterotonic drugs will ensure the success of strategies to reduce PPH.
Your challenge now is to assess: 1) how uterotonic drugs are stored in your facility, and 2)
how your managers calculate the quantity of uterotonic drugs to order for your facility. If
uterotonic drugs are not being stored in a way that will ensure their effectiveness or you
have found that there are stock-outs, discuss how to remedy these problems so that you
can be sure that uterotonic drugs that are effective are always available.
Congratulations!
You have successfully completed the core topic reviewing management of uterotonic drugs
used for AMTSL. Write down any questions you have for your mentor, relax a bit, and then
begin the next part of core topic 4: AMTSL.

Core Topic 4: AMTSL
Overview
Core topic 4 introduces the steps of AMTSL. After a demonstration of these steps, you will
practice skills in a simulated setting before working in the clinical area.
Learning objectives
By the end of this topic, participants will have the knowledge and skills to:
• Describe the steps of AMTSL.
• Correctly demonstrate the steps of AMTSL using the practice
checklist in a simulated and clinical setting.
Key definitions
Active management of the third stage of labor: A combination of actions performed
during the third stage of labor to prevent PPH. AMTSL speeds delivery of the placenta by
increasing uterine contractions and prevents PPH by minimizing uterine atony. The
components of AMTSL are:
1) Administration of a uterotonic agent within one minute after the baby is born after
ruling out the presence of another baby (oxytocin is the uterotonic of choice).
2) Controlled cord traction (CCT) with counter-traction to the uterus during a uterine
contraction.
3) Uterine massage immediately after delivery of the placenta to help the uterus
contract, as well as to assess uterine contraction.
Placenta accreta: A severe obstetric complication occurring when the placenta attaches
itself too deeply and too firmly into the wall of the uterus, preventing separation of the
placenta from the uterus.
Postpartum: Neither "postpartum period" nor "puerperium" (which are more or less
synonymous) are officially defined. WHO has, however, formally designated the first 28
completed days after birth of the infant as the neonatal period. Traditionally the postpartum
period ends 6 weeks after birth.
.

Essential care during the third stage of labor
The time immediately following birth can be particularly active and involved
because the skilled birth attendant must attend to both the woman and
newborn. Regardless of how the third stage of labor is managed, basic care
for the woman and baby during labor and postpartum remains the same.
The following actions represent the elements of essential care for the provider and for the
woman and newborn during the third stage of labor.
Essential precautions for the provider

Health care providers should take the following precautions for themselves:
Wear protective gear (gloves, face mask/goggles, apron, and boots or closed shoes).
Safeguard against splashes and sharps-related injuries.
Essential care for the woman

Health care providers should follow these guidelines in caring for the woman:
Ensure the woman is in a comfortable position.
Explain to woman and family what is happening around them.
Inform the woman about her baby and explain what is happening while you attend to
immediate newborn care.
Encourage breastfeeding, if this is the woman’s choice for infant feeding.
Follow national guidelines for maternal interventions to prevent/reduce the risk of
mother-to-child transmission (MTCT) of HIV/AIDS.
Throughout all phases of care:
− Give continuous empathetic and physical support.
− Give the woman as much information and explanation as she desires.
− Facilitate good communication among the woman and her caregivers
and companions.
− Practice infection prevention.
Essential care for the newborn
Health care providers should follow these guidelines when caring for the newborn:
Thoroughly dry and stimulate the baby while assessing breathing. If the baby is
not crying or breathing at least 30 times per minute within 30 seconds of birth,
call for help and begin resuscitation.
Place the newborn in skin-to-skin contact with the woman; cover both with a dry
warm cloth or blanket. Cover the baby’s head to ensure warmth (Figure 4-1).
If breastfeeding is the woman’s choice for infant feeding, place the baby close to
the woman’s breast to help encourage the baby to latch on to the breast.

Figure 4-1. Keeping the baby in skin-

to-skin contact with the mother.
(WHO, 1997)
Wait to clamp and cut the cord until two to three minutes after the baby’s birth.
(Even if oxytocin is given within one minute after birth of the baby, clamping
does not need to happen until two to three minutes after the baby’s birth.)
Note: In situations where cord clamping and cutting was

delayed, there were fewer cases of anemia in full-term babies
at two months of age and increased duration of early
breastfeeding.22
Immediate cord clamping can decrease the red blood cells an infant receives at birth
by more than 50 percent.23 Studies show that delaying clamping and cutting of the
umbilical cord is helpful to both full-term and preterm babies. In high-risk situations
(e.g., low birth weight or premature infant), delaying clamping by as little as a few
minutes is helpful. In situations where cord clamping and cutting was delayed for
preterm babies, these infants had higher hematocrit and hemoglobin levels and a
lesser need for transfusions in the first four to six weeks of life than preterm babies
whose cords were clamped and cut immediately after birth.
Follow national guidelines for newborn interventions to prevent/reduce the risk of
MTCT of HIV/AIDS.
Avoid separating the woman and her newborn. Never leave the
woman and newborn alone.


Preparing for active management
Before or during the second stage of labor:

Prepare the injectable uterotonic (10 IU of oxytocin is the
preferred injectable uterotonic) in a sterile syringe before
second stage (Figure 4-2) or have oxytocin in the Uniject
available. (NOTE: If oxytocin is not available, then use
ergometrine 2 mg IM, or Syntometrine 1 mL IM. If
injectable uterotonic drugs are not available or the birth
attendant’s skills are limited, use misoprostol 600 mcg
orally.)
Prepare other essential equipment for birth and the third
stage of labor before onset of the second stage of labor.
Ask the woman to empty her bladder when the second
stage is near.
Assist the woman into her preferred position for giving
birth (e.g., squatting, semi-sitting).
Figure 4-2. Preparing
oxytocin injection.
(Gomez et al., 2005)

Steps for AMTSL

Before reading this part of Learner’s Guidebook, watch the DVD “AMTSL: A
demonstration.” If you can’t watch it at this time, continue with your reading,
but try to watch it at some other time before you begin practicing it.
There are three main components or steps of AMTSL—administering a uterotonic drug, CCT,
and massaging the uterus—which should be implemented along with the provision of
immediate newborn care.
1. Thoroughly dry the baby, assess the baby’s

breathing and perform resuscitation if needed, and
place the baby in skin-to-skin contact with the
mother
After delivery, immediately dry the infant and assess the

baby’s breathing. Then place the reactive infant, prone, on
the mother’s abdomen. Remove the cloth used to dry the
baby and keep the infant, including her head, covered
with a dry cloth or towel to prevent heat loss.
Note: If the infant is pale, limp, or not breathing, it is best
to keep the infant at the level of the perineum to allow
optimal blood flow and oxygenation while resuscitative
measures are performed. Early cord clamping may be
necessary if immediate attention cannot be provided
without clamping and cutting the cord.
Figure 4-3. Put the baby on

the mother’s abdomen.
2. Administer a uterotonic drug within one minute of

the baby’s birth
Administering a uterotonic drug within one minute of the baby’s birth stimulates uterine
contractions that will facilitate separation of the placenta from the uterine wall and ensure
that the uterus remains contracted after the placenta has been delivered. Before giving the
uterotonic drug, it is important to rule out the presence of another baby (Figure 4-4). If the
uterotonic drug is administered when there is a second baby, there is a small risk that the
second baby could be trapped in the uterus.
The steps for administering a uterotonic drug include:
1. Before performing AMTSL, gently palpate the

woman’s abdomen to rule out the presence of
another baby. At this point, do not massage the
uterus.
Figure 4-4. Rule out the presence of

a second baby.

2. If there is not another baby, begin the
procedure by giving the woman 10 IU
of oxytocin IM in the upper thigh
(Figure 4-5). This should be done
within one minute of childbirth. If
available, a qualified assistant should
give the injection.
Figure 4-5. Give a uterotonic drug.
3. Cut the umbilical cord
1. Wait for cord pulsations to cease or approximately two to three minutes after
birth of the baby, whichever comes first, and then place one clamp 4 cm from the
baby’s abdomen (Figure 4-6).
Note: Delaying cord clamping allows for transfer of red blood cells
from the placenta to the baby that can decrease the incidence of
anemia during infancy.
2. Gently milk the cord towards the woman’s perineum and place a second clamp on
the cord approximately 2 cm from the first clamp.
3. Cut the cord using sterile scissors under cover of a gauze swab to prevent blood
spatter. After mother and baby are safely cared for, tie the cord.
Figure 4-6. Pulsating and nonpulsating umbilical cord.

4. Keep the baby warm
Place the infant directly on the mother’s chest,

prone, with the newborn’s skin touching the
mother’s skin (Figure 4-7). While the mother’s
skin will help regulate the infant’s temperature,
cover both the mother and infant with a dry,
warm cloth or towel to prevent heat loss. Cover
the baby’s head with a cap or cloth.
Figure 4-7. Keep the baby in skin-to-

skin contact with the mother.
5. Perform controlled cord traction
CCT helps the placenta descend into the vagina after it has separated from the uterine
wall and facilitates its delivery. It is important that the placenta be removed quickly once it
has separated from the uterine wall because the uterus cannot contract efficiently if the
placenta is still inside. CCT includes supporting the uterus by applying pressure on the lower
segment of the uterus in an upward direction towards the woman’s head, while at the same
time pulling with a firm, steady tension on the cord in a downward direction during
contractions. Supporting or guarding the uterus (called “counter-pressure” or “counter-
traction”) helps prevent uterine inversion during CCT. CCT should only be done during a
contraction.
Note: CCT is not designed to separate the placenta from the uterine wall but
to facilitate its expulsion only. If the birth attendant keeps pulling on an
unseparated placenta, inversion of the uterus may occur.
The steps for CCT include:
1. Place the clamp near the woman’s

perineum to make CCT easier (Figure
4-8).
Figure 4-8. Clamping the umbilical cord near

the perineum. (Gomez et al., 2005)

2. Hold the cord close to the
perineum using a clamp (Figure 4-
9).
3. Place the palm of the other hand
on the lower abdomen just above
the woman’s pubic bone to assess
for uterine contractions (Figure 4-
9). If a clamp is not available,
controlled cord traction can be
applied by encircling the cord
around the hand.
Figure 4-9. Palpate the next contraction.

4. Wait for a uterine contraction. Only do CCT when there is a contraction.
5. With the hand just above the pubic bone, apply external pressure on the
uterus in an upward direction (toward the woman’s head) (Figure 4-10).
6.
7. At the same time with your other
hand, pull with firm and steady
tension on the cord in a
downward direction (follow the
direction of the birth canal). Avoid
jerky or forceful pulling.
Figure 4-10. Applying CCT with countertraction to support the uterus.

NOTE: If the placenta does not descend during 30 to 40 seconds of CCT (i.e., there
are no signs of placental separation), do not continue to pull on the cord and follow
these steps:

o Gently hold the cord and wait until the uterus is well-contracted again. If
necessary, use a sponge forceps to clamp the cord closer to the perineum as it
lengthens.
o With the next contraction, repeat CCT with counter traction.
8. Do not release support on the

uterus until the placenta is
visible at the vulva. Deliver the
placenta slowly and support it
with both hands (Figure 4-11).
Figure 4-11. Supporting the placenta with

both hands.
NOTE: If the placenta does not descend after 4 attempts, consider placenta accreta and
seek assistance from another provider.
9. As the placenta is delivered, hold and gently turn it with both hands until
the membranes are twisted (Figure 4-12).
10. Slowly pull to complete the delivery. Gently move membranes up and
down until delivered (Figure 4-12).
Figure 4-12. Delivering the placenta with a turning and up-and-down motion.
NOTE: If the membranes tear, gently examine the upper vagina and cervix wearing
high-level disinfected or sterile gloves and use a sponge forceps to remove any
pieces of remaining membrane.

6. Massage the uterus
Massage the uterus immediately after

delivery of the placenta and membranes until
it is firm (Figure 4-13). Massaging the uterus
stimulates uterine contractions and helps to
prevent PPH. Sometimes blood and clots will
be expelled during this process. After
stopping massage, it is important that the
uterus does not relax again.
Figure 4-13. Massaging the uterus

immediately after the placenta delivers.
Instruct the woman how to massage

her own uterus, and ask her to call if
her uterus becomes soft (Figure 4-14).
Figure 4-14. Teach the woman how to massage her

own uterus.
Learning activity 4.2. (Estimated time to complete this


Care after delivery of the placenta

7. Examine the placenta
Examine the fetal and maternal sides of the placenta and membranes to
ensure they are complete. A small amount of placental tissue or membranes
remaining in the woman can prevent uterine contractions and cause PPH.
Note: Follow infection prevention guidelines when handling

contaminated equipment, supplies, and sharps.
To examine the placenta for completeness:

1. Hold the placenta in the palms of the hands with the
maternal side facing upward and make sure that all
lobules are present and fit together (Figure 4-15).
Figure 4-15. Examining the maternal side of

the placenta. (Gomez et al., 2005)
2. Hold the cord with one hand, allowing the

placenta and membranes to hang down. Place
the other hand inside the membranes, spreading
your fingers to ensure that membranes are
complete (Figure 4-16).
3. Dispose of the placenta as appropriate.
Figure 4-16. Checking the

membranes. (Gomez et al., 2005)

8. Examine the lower vagina and perineum
1. Gently separate the labia and inspect the

lower vagina and perineum for lacerations
that may need to be repaired to prevent
further blood loss (Figure 4-17).
2. Repair lacerations or episiotomy.
Figure 4-17. Gently inspect the lower

vagina and perineum for lacerations.
3. Gently cleanse the vulva, perineum, buttocks, and back with warm water and a
clean compress.
4. Apply a clean pad or cloth to the vulva.
5. Evaluate blood loss.
6. Explain all examination findings to the woman and, if she desires, her family.
9. Provide immediate care
After examining the placenta and external genitals, continue caring for the mother and
newborn. The first six hours after delivery is the period when many preventable maternal
deaths occur. The woman and newborn should be kept in the labor and delivery ward and
closely monitored for at least the first hour after childbirth. She and the newborn may be
transferred to the postpartum ward one hour after childbirth but they should continue to be
closely monitored during at least the first 6 hours on the ward and should not be
discharged before 12 hours after childbirth. A comprehensive exam of the woman and
newborn should be performed at one and six hours after delivery.
This is a very critical time to be sure that complications, such as postpartum haemorrhage
and hypothermia, do not occur.
• Provide the woman with information about how she and her baby will be cared for
during the next few hours.
• Keep the woman and the newborn in the delivery room for at least one hour after
childbirth – do not separate them.

• Ensure the room and any surface the baby is put on are warm; maintain skin-to-skin
contact with the mother.
• Never leave the woman and newborn alone. Keep the baby in the room with the
mother, in skin-to-skin contact.
• If the woman still does not know her HIV status, then offer HIV testing and
counseling.
• Monitor the woman and baby every 15 minutes during the first two hours, then
every 30 minutes during the third hour, and then every hour for three hours. Record
findings on the postpartum record
If the woman has chosen to breastfeed, the

mother and baby may need assistance to
breastfeed within the first hour after the
birth and before transferring them out of
the delivery room (Figure 4-18). Assess
readiness of the woman and newborn to
breastfeed before initiating breastfeeding;
do not force the mother and baby to
breastfeed if they are not ready.
Figure 4-18. Encourage breastfeeding within

the first hour after birth.
Care for the woman

• Encourage the woman to eat, drink and rest.
• Ask the companion to stay with the woman
• Ensure the woman has sanitary napkins or clean material to collect vaginal blood.
• Encourage the woman to empty her bladder and ensure that she has passed urine. Only
catheterize the woman if she is unable to urinate and her bladder is distended.
• Ask the woman’s companion to watch her and call for help if bleeding or pain increases,
if mother feels dizzy or has severe headaches, visual disturbance or epigastric distress.
• Ensure the room is warm (25°C).
• Keep the mother and baby together.
• Never leave the woman and newborn alone.
• Provide additional care if the woman is infected with HIV:
- Instruct her on how to take her ARV drugs.
- Instruct her on how to administer ARV drugs to her newborn baby.
- Tell her that lochia can cause infection in other people and therefore she
should dispose of blood stained sanitary pads safely (list local options).
- Counsel her on family planning.
- If not breastfeeding, advise her on breast care.
• Document all findings and care provided.

Just prior to transfer out of the delivery room or at least one hour after childbirth, the
provider will perform a comprehensive exam of the woman.
Care for the newborn

• Wipe the eyes, and apply an antimicrobial within 1 hour of birth.
• If blood or meconium are present, wipe off with wet cloth and dry the skin immediately
with a dry cloth (make sure to wear gloves when handling the cloth; advise the family
on how to handle and clean the cloth).
• DO NOT remove vernix and do not bathe the baby until at least 6 hours after birth.
• Continue keeping the baby warm and in skin-to-skin contact with the mother.
• Administer Vitamin K1 (1 mg for babies ≥1500 g and 0.5 mg for babies <1500 g), if not
yet done.
• If the mother was not counseled on infant feeding options, counsel her immediately after
delivery.
• Help the mother to initiate the feeding option of her choice:
- If she is using formula, place the infant on her body for skin-to-skin
contact, prepare safe formula feeding and help with the first feeding when
the baby is ready. Support the mother to prepare formula feeding and feed
safely.
- If she has chosen exclusive breastfeeding, encourage her to initiate
breastfeeding when the baby shows signs of readiness. Offer her help.
• Provide additional care if the newborn was exposed to HIV:
- Give antiretroviral (ARV) drugs
Careful information and assistance will need to be provided to the mother, father and
family members (based on the choice of the mother) to ensure that the newborn
receives the complete prescribed ARV prophylaxis. Some mothers may not want to
openly give ARVs, or may decide to stop the ARVs if the baby is having side effects,
or may decide that the ARVs are not necessary because the baby does not have any
symptoms. When working with mothers and families, provide the following
information to ensure adherence to the newborn ARV regimen:
Reasons for giving ARV drugs to the newborn
Importance of completing the entire prescribed course of ARV drugs
Strategies to give ARV drugs to the newborn
Strategies to manage questions about giving ARV drugs to the newborn
Recognition and management of side effects.
- If the mother infected with HIV was not counseled on infant feeding
options, counsel her immediately after delivery
- Help the mother to initiate the feeding option of her choice:
contact, prepare safe replacement feeding and help with the first feeding
when the baby is ready. Support the mother to prepare formula feeding
and feed safely.

Document findings and care provided

Record the following information in the maternal care record:
• Findings
• Treatments and prophylaxis provided during labor and in the first hour after delivery of
the placenta
.
• Procedures
10. Monitor the woman and newborn after
delivery of the placenta
Monitoring the woman 0-6 hours after delivery of the

placenta
During hours 0 to 6 after delivery of the placenta, the provider will monitor the woman as
follows:
Danger signs:
Uterine contractedness, vaginal • Diastolic BP ≥90 mmHg
• Systolic BP <60 mmHg
bleeding, blood pressure, and pulse • Pulse >110 beats/min
• Pad soaked in less than 5 minutes
• Constant trickle of blood
- every 15 minutes for 1 • Estimated blood loss of 250 ml or more or a
hour, then woman who gave birth at home and presents
- every 30 minutes for the with persistent vaginal bleeding
third hour, then • Uterus is neither hard nor round
• Genital laceration extending to the anus or
- every hour for 3 hours rectum.
Danger signs:
• Temperature > 38°C
• Rapid breathing
• Palmar or conjunctival pallor • Temperature and respirations
associated with 30 - every 4 hours
respirations per minute or
more (the woman is quickly
fatigued or has rapid
breathing at rest)
Danger signs:
• The woman cannot void on
• Urinary bladder (assist the woman to empty
her own and her bladder is
her bladder if it is distended / full)
distended and the woman is
- every hour uncomfortable
• Urinary incontinence

Danger signs:
• The baby is not taking the
• Breastfeeding
breast well
• Breastfeeding has not yet - Every hour (without forcing the baby / mother to
been initiated feed)
Danger signs:
• Psychological reactions
• Negative feelings about
- every hour herself or the baby
Monitoring the newborn 0-6 hours after delivery of the

placenta
The mother and newborn should always be kept together, unless there are medical reasons
for separating them. The provider will monitor the newborn at the same time as she/he
monitors the postpartum woman.
Before checking the baby, explain what is being done and why to the mother/parents.
If all findings are within normal limits, share this with the mother/parents. If even 1
danger sign is present, respond immediately and explain what is happening to the
mother/parents.
Monitor the newborn at the same time as the mother:
o every 15 minutes for the first two hours, then
o every 30 minutes for the third hour, then
o every hour for 3 hours
Monitor the following parameters in the newborn:
• Respiration: Count the number of
respirations in 1 minute. Listen for Danger signs:
grunting, look for in-drawing of the chest
and fast breathing. • Rapid respirations (more than 60
respirations per minute).
• Temperature: Check to see if the baby’s
• Slow respirations (less than 30
feet, hands, and abdomen are cold to
respirations per minute).
touch – if they are cold then check axillary
• Grunting.
temperature.
• Convulsions.
If the palms of the hands or the soles of • Generalized cyanosis or pallor.
the feet are cold or blue, this may be • Cyanosis of the extremities
because the baby is not warm enough. If (acrocyanosis), pink body.
the abdomen is cold, this usually means • Cold feet.
the baby has some degree of hypothermia
• Temperature < 36.5°C.
and requires immediate attention. Keep
• Temperature > 37.5°C.
the baby in skin-to-skin contact with the
• Umbilical cord bleeding.
mother and cover the baby with additional
warm covers.
• Color: Check the baby’s color. The mouth, including the tongue, the palms of the
hands and the soles of the feet should be pink. If the palms of the hands and the
soles of the feet are blue, even if the baby’s tongue is pink and the baby seems

normal, this “acrocyanosis” may mean that the baby is not warm enough and
requires additional thermal protection.
• Check for cord bleeding: If the cord is bleeding, check to make sure that it is well
tied. If the cord continues to bleed and it is well attached, consult a doctor as this
may mean the baby has a clotting disorder.
• Check for congenital anomalies: If this was not done before, check for congenital
anomalies that require special care at birth:
o Cleft lip or palate: If the baby is being breastfed, this may require feeding the
baby with a cup and spoon.
o Esophageal atresia: this anomaly is usually associated with excessive salivation
o Neural tube defects
o Imperforate anus
N.B. The last 3 congenital anomalies require urgent transfer to a facility
with pediatric operative facilities.


Examinations of the woman and newborn one
hour after delivery of the placenta
A complete assessment of the woman and newborn should be performed at
1 hour and 6 hours after the birth. A special examination will need to be
performed if the newborn is preterm, weighs less then 2500 grams or is a
twin.
Assess the woman at 1 hour and 6 hours after delivery:
• Check record for postpartum bleeding >250 mL, completeness of the placenta and
membranes, complication during delivery or postpartum, special treatment needs, and
desire for tubal ligation or IUD
• Ask the woman :
− How she is feeling
− If she has pain
− If she has any concerns or is bleeding heavily
− How her baby is
− How her breasts feel
− If she has any pain
− If she has any questions or difficulties with regard to feeding her infant
• Assess the woman:
− Check for conjunctival and palmar pallor.
− Measure blood pressure and pulse
− Measure temperature.
− Feel the uterus. Is it hard and round?
− Look for vaginal bleeding
− Look at the perineum.
• Is there a tear or cut?
• Is it red, swollen or draining pus?
− Ask the woman to feed her baby to evaluate if she needs assistance
− Respond immediately if there any problems
• For the woman who is HIV infected:
− Check the record for administration of ARV drugs, and time for subsequent dose.
− Administer ARV drugs, based on schedule. Also plan subsequent dose.
Assess the baby at 1 hour and 6 hours after delivery:
• Check maternal and newborn record or ask the mother:
− How old is the baby?
− Preterm (less than 37 weeks or 1 month or more early)?
− Breech birth?
− Difficult birth?
− Resuscitated at birth?
− Has baby had convulsions?

• Ask the mother:

− Do you have concerns?
− How is the baby feeding?
• Is the mother very ill or transferred?
• Assess breathing (baby must be calm): listen for grunting, for chest in-drawing and
check for the respiratory rate (30-60/min, normally), repeat the count if elevated
• Observe the movements, and check for any asymmetry or lack of movement of part of
the body, or any abnormal movement
• Look at abdomen for pallor.
• Check the umbilical cord for bleeding.
• Look for malformations.
• Feel the tone: is it normal?
• Check for the presence of bruises and swelling of the presenting part
• Feel for warmth. If cold, or very warm, measure temperature.
• Respond immediately if there any problems
• For the HIV exposed infant (born to an HIV infected mother), check for administration of
ARV drugs and develop a plan for ARV prophylaxis drug administration


Management of the third stage of labor when the
birth attendant is alone and the baby needs
resuscitation
There is a potential “conflict of interest” in care for the mother and baby
when the baby needs resuscitation. How the provider cares for each one will
depend upon several factors: if the birth attendant is alone or has an
assistant and what type of resuscitative efforts are required for the baby.
If the birth attendant is alone and the baby is not breathing or is gasping at birth, the birth
attendant will manage the third stage of labor as follows:
Scenario 1: The baby begins breathing after stimulation.
1) Administer a uterotonic drug within one minute after the baby is born (oxytocin is
the uterotonic of choice) and a second twin has been ruled out.
2) Apply controlled cord traction (CCT) with simultaneous countertraction to the
uterus.
3) Perform uterine massage immediately after delivery of the placenta.
Scenario 2: The baby requires resuscitation with bag and mask.
1) Administer a uterotonic drug within one minute after the baby is born (oxytocin
10 IU IM or misoprostol 600 mcg po) and a second twin has been ruled out.
Note: Do not use ergometrine or Syntometrine in the case where CCT may not be
possible. Ergometrine causes tonic clonic contractions that may entrap the
placenta.
2) Deliver the placenta either by maternal effort or, if it is possible, controlled cord
traction (CCT) with simultaneous countertraction to the uterus.
Scenario 3: The baby requires resuscitation and the birth attendant is not able to administer
a uterotonic drug
1) Manage the third stage physiologically.


Management of the third stage of labor in the

context of HIV
The practice of AMTSL is the same for all women regardless of their HIV
status. However, women who are HIV infected may choose not to
breastfeed, so providers need to respect and support the woman’s choice for
infant feeding. In addition, providers need to ensure that national guidelines for PMTCT are
implemented for the woman and newborn in addition to routine care during labor, childbirth,
and in the immediate postpartum.
To help ensure safety, providers caring for all newborns should:
Not suction unless infant does not breathe within 30 seconds of birth. Use either
mechanical suction at less than 100 mm Hg pressure or bulb suction, rather than
mouth-operated suction.
Not milk the cord toward the baby before cutting the cord.
Use separate scissors for episiotomy and cord-cutting.
If the mother infected with HIV was not counseled on infant feeding options, counsel her
immediately after delivery
Help the mother to initiate the feeding option of her choice:
contact, prepare safe replacement feeding and help with the first feeding
when the baby is ready. Support the mother to prepare formula feeding
and feed safely.
Give antiretroviral (ARV) drugs according to national protocols.


Frequently asked questions
How is a newborn affected if 10 IU of oxytocin IM is given before

clamping the cord?
There are no known harmful effects from giving oxytocin before cord clamping. Mothers
naturally produce some oxytocin during labor which is transmitted to the infants. Oxytocin
given either IM or IV at delivery supplements this natural process.
Also, giving a uterotonic drug immediately after birth can speed the transfer of blood into
the baby from the placenta. This increases the infant’s red cell mass.22
Are there more complications with AMTSL such as a ruptured cord (cord tears off),
inverted uterus, or retained placenta?
Some providers express concern that active management increases uterine inversion rates
and ruptured cords due to cord traction and increases the risk of retained placenta due to
entrapment caused by uterotonic drugs. However research24 shows:
No uterine inversions were seen in any of the trials comparing active and physiologic
management. However, these trials were not designed to evaluate very rare
outcomes.
Trials using oxytocin alone showed reduced rates of manual removal of the placenta,
whereas those using ergot preparations (e.g., ergometrine) showed increased
rates.
The trial findings did not show increased risk of cord rupture.
If oxytocin is supplied in 5 IU ampoules, is one ampoule sufficient for performing
AMTSL?
Although the recommended dose of oxytocin has changed over the years, WHO now
recommends administering 10 IU of oxytocin IM for AMTSL. Trials comparing active and
physiologic management have also compared the different uterotonics in active
management protocols. Results suggest that increasing the intramuscular dose of oxytocin
from 5 IU to 10 IU increases its effectiveness.3, 4
Will routine manual exploration of the uterus after AMTSL help reduce the
incidence of PPH from retained placenta or placental fragments?
Routine manual exploration of the uterus is no longer recommended for normal deliveries or
those following previous cesarean delivery. Manual exploration is painful and may likely
increase the risk of complications, especially infections. Exploration is justified for women
with a well-contracted uterus experiencing bleeding from high in the genital tract.
Will “milking” the cord help to increase the baby’s hemoglobin?

Because there is no documented benefit from the practice, “milking” the cord toward the
baby to exaggerate the transfer of blood to the newborn is discouraged. “Milking” the cord
towards the mother just prior to cutting the cord is encouraged to reduce the risk of blood
splashing when the cord is cut.
WHO supports the practice of delayed cord clamping. Delaying cord clamping for 2 to 3
minutes has proven beneficial to the baby as it results in higher hemoglobin and hematocrit
values and possibly lower levels of early childhood anemia and greater iron stores.25 This

may be particularly important for low birthweight and premature infants. If maternal
bleeding in the first few minutes after childbirth is significant, a decision to delay cord
clamping for 2 to 3 minutes must be determined by assessing the risk of PPH with the
benefit of delayed cord clamping.
What are the risks of giving oxytocin for AMTSL when there is an undiagnosed
multiple pregnancy?
There is a theoretical risk of a trapped twin if providers administer oxytocin with an
undiagnosed twin. Original research trials on AMTSL that established its effectiveness
included giving a uterotonic drug with birth of the anterior shoulder.3, 4 However, updated
AMTSL protocols take the theoretical risk of a trapped twin into account and now
recommend giving oxytocin after the birth of the baby and only after excluding the presence
of an additional baby. Quality clinical assessment in labor and following delivery of the first
baby can establish the diagnosis before giving a uterotonic drug.
If the woman has an IV infusion running at the time the baby is born, how should
oxytocin be delivered (dosage and route) for AMTSL?
Typically with vaginal delivery, a dose of 10 IU of oxytocin is administered IM. In patients
with an IV, the provider may give 5 IU of oxytocin as a slow intravenous bolus and then
continue with the oxytocin infusion.
What part does each of the steps of AMTSL play in preventing PPH?
Trials that administered uterotonics at the time of delivery with physiologic management
showed some reduction in PPH rates. However, a greater reduction in PPH rates is evident
with AMTSL. In cases where a uterotonic drug is given without CCT, women experienced a
greater incidence of retained placenta; additionally, no reduction in the number of patients
26
receiving blood transfusions was detected.
A single trial examined the effect of CCT with and without the administration of oxytocin
after delivery of the baby. The results suggest that CCT alone does not reduce the incidence
of PPH or severe PPH. Another trial found that CCT used with oxytocin immediately after
placental delivery resulted in outcomes similar to those with using all three components of
27
AMTSL. A third trial showed that true active management resulted in lower PPH rates
28
when compared with CCT followed by oxytocin at the time of placental delivery.
Should CCT be performed by a skilled birth attendant if there are no uterotonic

drugs?
CCT is not recommended unless uterotonic drugs are used or a skilled birth attendant is
present. If CCT is applied in the absence of uterotonic drugs or a skilled birth attendant, the
practice can cause partial placental separation, and might increase the risk of a ruptured
cord, excessive bleeding, and uterine inversion.
Should uterine massage be performed by a skilled birth attendant before the

delivery of the placenta?
There is no evidence to support the recommendation of providing uterine massage before
delivery of the placenta in the absence of a uterotonic drug, and evidence is increasing that
uterine massage before delivery of the placenta may lead to increased rates of PPH.

How should the third stage of labor be managed in the absence of uterotonic
drugs?
In some settings there will be no uterotonics available due to interruptions of supplies or the
setting of birth. In the absence of current evidence, ICM and FIGO recommend that when no
uterotonic drugs are available to either the skilled or non-skilled birth attendant,
management of the third stage of labor includes the following components21 (see Appendix
A):
• Waiting for signs of separation of the placenta (cord lengthening, small blood loss,
uterus firm and globular on palpation at the umbilicus)
• Encouraging maternal effort to bear down with contractions and, if necessary, to
encourage an upright position
• Abstaining from using CCT, since in the absence of uterotonic drugs, or prior to signs
of separation of the placenta, this can cause partial placental separation, a ruptured
cord, excessive bleeding, and uterine inversion
• Massaging the uterus after the delivery of the placenta as appropriate.
How should the third stage of labor be managed in situations where no oxytocin is
available or birth attendants’ skills are limited?
In situations where no oxytocin is available or birth attendants’ skills are limited, the 2006
FIGO/ICM joint statement recommends administering misoprostol soon after the birth of the
baby to reduce the occurrence of hemorrhage.21 The most common side effects are
transient shivering and pyrexia. Education of women and birth attendants in the proper use
of misoprostol is essential.
The usual components of giving misoprostol include:
• Administration of 600 mcg misoprostol orally or sublingually after the birth of the
baby.
• Uterine massage after the delivery of the placenta as appropriate.
In the absence of active management, should uterotonic drugs be used alone for
prevention of PPH?
The most recent WHO recommendations for the prevention of PPH20 promote the use of a
uterotonic drug (oxytocin or misoprostol) by a health worker trained in its use for
prevention of PPH in the absence of active management of the third stage of labor. This
recommendation is based on results from two randomized trials and places a high value on
the potential benefits of avoiding PPH. In the case of misoprostol, there is the additional
benefit of ease of administration of an oral drug in settings where other care is not
available.

Does nipple stimulation prevent PPH?

Nipple stimulation results in the release of the oxytocin hormone in the woman. The nipples
are easily stimulated through early breastfeeding. Research has not shown that nipple
stimulation significantly helps to reduce the risk of PPH, so this should not replace AMTSL to
prevent PPH. However, promoting breastfeeding after birth has several benefits:
Stimulates natural production of oxytocin.
Helps maintain tone of the contracted uterus.
Promotes bonding between the mother and newborn.
Nourishes infants and protect them from illness.


Summary
You have just reviewed recommendations for maternal and newborn care during the third
stage of labor and in the first 2 hours postpartum. After completing this section, you should
have the theoretical foundation for applying AMTSL. Having this theoretical knowledge is not
enough to be able to apply AMTSL in the clinical area. You will now need to schedule a time
with your mentor to practice the skills on an anatomical model before applying the skills in
the clinical area. If possible, observe providers practicing AMTSL before practicing on an
anatomical model. When you observe a provider, use your checklist to evaluate how they
are doing. Are there differences in how they practice AMTSL and what is on the evaluation
checklist? If there are differences, make sure that you follow the steps as described in the
practice checklist.
Congratulations!
You have successfully completed the theoretical portion of the PPPH course. Review all of
the material in the learner’s guide and prepare yourself for the mid-course questionnaire.
Talk with your mentor and learning partner to find a time to work on demonstrations and
get ready for your clinical practicum.

Additional Topic 1: Prevention of infections

Sources: This section provides guidelines on infection prevention practices to use when
providing maternal and newborn services and is adapted from materials developed by
JHPIEGO, EngenderHealth, and WHO. 29, 30, 31
Overview
Understanding and using infection prevention practices is important for preventing major
infections while providing care. These practices reduce the risk of transmission of serious
diseases such as hepatitis B, hepatitis C, and HIV/AIDS during the provision of maternal and
newborn care services. This topic covers important infection-prevention principles, focusing
on handwashing, waste disposal, and proper use of gloves, aprons, and needles. This
section also covers the four steps needed for processing instruments and supplies.
Learning objectives
• Explain the five basic principles of infection-prevention practices.
• Describe ways to protect oneself and others from infection focusing on
handwashing, proper waste disposal, use of gloves, aprons, and other
protective gear, and injection safety.
• Describe the four steps for decontaminating instruments.
• Explain how to mix a 0.5 percent chlorine decontamination solution.
Key definitions
Decontamination: The first step in processing instruments and other items for reuse.
Decontamination kills viruses (such as hepatitis B, other hepatitis viruses, and HIV) and
many other microorganisms, making these items safer to handle by the staff that perform
cleaning and further processing. This requires a ten-minute soak in a 0.5 percent chlorine
solution.
Cleaning: The second step in processing instruments that refers to scrubbing with a brush,
detergent, and water to remove blood, other body fluids, organic material, tissue, and dirt.
In addition, cleaning greatly reduces the number of microorganisms (including bacterial
endospores) on items and is a crucial step in processing. If items have not first been
cleaned, further processing might not be effective.
High-level disinfection (HLD): The process that destroys all microorganisms (including
bacteria, viruses, fungi, and parasites), but does not reliably kill all bacterial endospores,
which cause diseases such as tetanus and gas gangrene.
Sterilization: The process that destroys all microorganisms (bacteria, viruses, fungi, and
parasites), including bacterial endospores, from instruments and other items.

Principles of infection prevention
Infection prevention (IP) has two primary objectives:

1. Prevent major infections when providing services.
2. Minimize the risk of transmitting serious diseases such as hepatitis B and
HIV/AIDS to the woman and to service providers and staff, including cleaning and
housekeeping personnel.
Infection prevention practices are based on the following five principles:
1. Every person (client or staff) is considered potentially infectious.
2. Hand washing is the single most important practice for preventing
cross-contamination.
3. Wear gloves before touching anything wet—broken skin, mucous membranes,
blood, or other body fluids.
4. Use protective gear (aprons, face masks, eye goggles) when splashes or spills of
body fluids are expected.
5. Use safe work practices (e.g., do not recap or bend needles), following guidelines
for handling and cleaning instruments and disposing of sharps and medical
waste.
Handwashing
The steps in hand washing are:
1. Wet hands with running water and apply soap.
2. Rub together all surfaces of the hands including wrists, between
fingers, palms, the back of the hands, and under fingernails.
3. Wash for 15 seconds.
4. Rinse under a stream of running water.
5. Dry hands. Air dry, or use a clean cloth or paper towels.
Always wash hands:
Upon arrival to and before leaving the health care facility.
Before and after examining the woman or baby (or having any direct contact).
After exposure to any blood or body fluids, even if gloves are worn.
After removing gloves (the gloves may have very small holes).

Figure 5-1. Washing hands. (EngenderHealth, online course:

http://www.engenderhealth.org/ip/handwash/hw6.html)


Gloves
Wear gloves when:

Performing a procedure.
Handling soiled items (e.g., instruments and gloves).
Disposing contaminated waste.
A separate pair of gloves must be used for each woman to avoid cross-contamination.
Disposable gloves are preferred, but when resources are limited, surgical gloves can be
reused if they are:
Decontaminated by soaking in 0.5 percent chlorine for ten minutes AND
Washed and rinsed AND
Sterilized by autoclaving or high-level disinfected by boiling or steaming.
Single-use or disposable surgical gloves should not be reused more than three times
because invisible tears may occur.
Note: Do not use gloves that are cracked, peeling, visibly torn,
or contain holes.
Putting on gloves
Follow the steps below in putting gloves on.
Step 1. Preparation for putting on surgical gloves. “Gloves are cuffed to make it easier to
put them on without contaminating them. When putting on sterile gloves, remember that
the first glove should be picked up by the cuff only (see drawing below). The second glove
should then be touched only by the other sterile glove.” Follow steps 2-6 as illustrated
below.
Figure 5-2. Putting gloves on. (EngenderHealth, online course:

http://www.engenderhealth.org/ip/surgical/sum4.html)

Removing gloves
Figure 5-3. Removing gloves. (EngenderHealth, online course:

http://www.engenderhealth.org/ip/surgical/sum4.html)
Aprons or gowns
Wear a clean or sterile gown during delivery:
If the gown has long sleeves, gloves should be placed over the gown sleeve to avoid
contaminating the gloves.
Ensure gloved hands are held high above the level of the waist and do not come into
contact with the gown.


Handling sharp instruments
Do not leave sharp instruments or needles (“sharps”) in places other than “safe”
zones:
− Use a tray or basin to carry and pass sharp items.
− Pass instruments with the handle (not the sharp end) pointing toward
the receiver.
Announce to others before passing sharps.
Needles and syringes

Follow these guidelines to ensure safe handling of needles and syringes:
Use each needle and syringe only once.
Do not take needle and syringe apart after
use.
Do not recap, bend, or break needles before
disposal.
Dispose of needles and syringes in a
puncture-proof container.
Where disposable needles are not available and
you must recap the needle, use the “one-hand
32
technique” for recapping (Figure 5-1).
Step 1: Place the cap on a hard, flat surface.
Step 2: Hold the syringe with one hand and use
the needle to “scoop up” the cap.
Step 3: When the cap covers the needle
completely, hold the base of the needle and use
the other hand to make sure the cap is firmly in
place.
Figure 5-4. One-hand technique for
needle recapping. (WHO and US CDC,
2003)
Preventing splashes
Wear appropriate protective goggles, gloves, and gown during delivery. Prevent splashes
from blood or amniotic fluid by following these guidelines:
Avoid snapping the gloves when removing, as this may cause contaminants to splash
into the eyes, mouth, or on to skin or others.
Hold instruments and other items under the surface of the water while scrubbing and
cleaning to avoid splashing.
Place items gently into the decontamination bucket to avoid splashes.
Avoid rupturing membranes during a contraction.
Stand to the side when rupturing membranes to avoid splashes from amniotic fluid.

Caution: If blood or body fluids get in the mouth or on skin,

wash with liberal soap and water as soon as it is safe for the
woman and baby. If blood or body fluids splash in your eyes,
irrigate well with water.
Learning activity 5.3 (Estimated time to complete this activity:

15 minutes)
Waste disposal
The purpose of waste disposal is to:

Prevent the spread of infection to people who handle the waste.
Prevent the spread of infection to the local community.
Protect those who handle waste from accidental injury.
There is no risk from non-contaminated waste such as office paper, which can be disposed
of according to local guidelines.
Proper handling of contaminated waste (such as items with blood or body fluids) is required
to minimize the spread of infection to other staff and the community. Proper handling
includes:
Wearing heavy-duty gloves.
Transporting solid contaminated waste to the disposal site in covered containers.
Carefully pouring liquid waste down a drain or flushable toilet.
Burning or burying contaminated solid waste.
Washing hands, gloves, and containers after disposal of infectious waste.


The steps of processing instruments
Source: JHPIEGO. Infection Prevention: Guidelines for Healthcare Facilities
with Limited Resources. JHPIEGO: Baltimore, 2003.
Proper processing involves several steps that reduce the risk of transmitting infections from
used instruments and other items to health care workers and clients: 1) decontamination,
2) cleaning, 3) either sterilization or high-level disinfection (HLD), and 4) storage. For
proper processing, it is essential to perform the steps in the correct order. Table 5-1
provides an overview of the benefits gained by performing each step when processing
instruments and gloves.
Decontamination
Cleaning
Sterilization High-Level Disinfection
Chemical (HLD)
Autoclave Boil or steam
Chemical
Storage
(cool, then use immediately or store)
Figure 5-5. Steps in process instruments

(http://www.reproline.jhu.edu/english/4morerh/4ip/gifs/slide18.gif )

Table 5-1. Steps and benefits for processing instruments for reuse
Processing step Benefit

Kills viruses (hepatitis B and C, HIV) and many other
germs.
Step Makes items safer to handle during cleaning.
Decontaminate
1 Makes items easier to clean.
Common decontamination process: soak in 0.5% chlorine
solution for 10 minutes.
Removes blood, other body fluids, tissue, and dirt.
Reduces the number of germs.
Step
Makes sterilization or HLD effective. If blood clot remains
Clean on instrument, germs in clot may not be completely killed
2
by sterilization or HLD.
Wash items with soap and water and rinse with clean
water.
Kills all germs except some endospores.
Use for items that have contact with broken skin or intact
mucous membranes.
High-level If sterilization is not possible, HLD may be the only other
disinfect choice.
Step Can be done by boiling or steaming items for 20 minutes
3 or chemical disinfection using 0.1% chlorine solution for 20
minutes.
Kills all germs including endospores.

Sterilize May not be possible in all settings.
Can be done by dry (oven) or wet heat (autoclave).
If items are stored properly they will not become

contaminated after processing. Proper storage is as
Step important as proper processing.
Store or Use
4 Store or use items properly after completing the first three
steps to prevent contamination for up to one week in HLD
container.
HLD: High-level disinfection

Making a chlorine decontamination solution
The ability to decontaminate instruments is a critical step in infection prevention. The most
common decontamination process is to soak instruments in a 0.5 percent chlorine solution
for ten minutes. Chlorine solutions made from sodium hypochlorite are usually the most
inexpensive, fast-acting, and effective for decontamination. A chlorine solution can be made
from:
Liquid household bleach (sodium hypochlorite).
Bleach powder or chlorine compounds available in powder form (calcium hypochlorite
or chlorinated lime).
Chlorine-releasing tablets (sodium dichloroisocyanurate).
Chlorine-containing compounds contain a certain percentage of "active" (or available)
chlorine. Active chlorine in these products kills microorganisms. The amount of active
chlorine is usually described as a percentage and differs among products, an important fact
to ensure preparation of a chlorine solution with 0.5 percent "active" chlorine that can be
used to decontaminate gloves, instruments, etc.
Note that:
• Different products may contain different concentrations of available chlorine and the
concentration should be checked before use.
• In countries where French products are available, the amount of active chlorine is
usually expressed in "degrees chlorum." One degree chlorum is equivalent to 0.3
percent active chlorine.
• Household bleach preparations can lose some of their chlorine over time. Use newly
manufactured bleach if possible. If the bleach does not smell strongly of chlorine it may
not be satisfactory for the purpose and should not be used.
• Thick bleach solutions should never be used for disinfection purposes (other than in
toilet bowls) as they contain potentially poisonous additives.
When preparing chlorine solutions for use, note that:
• Because of their low cost and wide availability, chlorine solutions prepared from liquid or
powdered bleach are recommended.
• Organic matter destroys chlorine, and freshly diluted solutions must therefore be
prepared whenever the solution looks as though it needs to be changed (such as when it
becomes cloudy or heavily contaminated with blood or other body fluids).
• Chlorine solutions gradually lose strength, and freshly diluted solutions must therefore
be prepared daily.
• Calculate the ratio of water to liquid bleach, bleach powder, or chlorine-releasing tablets
(see the calculations below).
• Clear water should be used to make the solution because organic matter destroys
chlorine.
• Use plastic containers for mixing and storing bleach solutions as metal containers are
corroded rapidly and also affect the bleach.
• Prepare bleach solutions in a well-ventilated area because they give off chlorine.
• Label the container with “___ (0.1 or 0.5) percent chlorine decontamination solution,”
and note the day and time prepared.
• 0.5 percent bleach solution is caustic. Avoid direct contact with skin and eyes.

Calculating the water to liquid household bleach ratio to make a 0.5

percent chlorine solution
Chlorine content in liquid bleach is available in different concentrations. You can use any
concentration to make a 0.5 percent chlorine solution by using the following formula:
[% chlorine in liquid bleach divided by 0.5%] minus 1 = parts of water for
each part bleach
Note: "Parts" can be used for any unit of measure (e.g., ounce,
liter, or gallon) and do not have to represent a defined unit of
measure (e.g., pitcher or container).
For example: To make a 0.5 percent chlorine solution from a 3.5 percent chlorine
concentrate, use one part chlorine and six parts water:
+
[3.5% divided by 0.5%] minus 1 = [7] minus 1 = 6 parts water for each part
chlorine
Calculating the water to bleach powder ratio to make a 0.5 percent

chlorine solution
When using bleach powder to make a decontamination solution, calculate the ratio of bleach
to water using the following formula:
[% chlorine desired divided by % chlorine in bleach powder] times 1,000 =
grams of powder for each liter of water.
Note: When bleach powder is used, the chlorine solution will

likely appear cloudy or milky.
For example: To make a 0.5 percent chlorine solution from calcium hypochlorite powder
containing 35 percent available chlorine, use the following formula:
[0.5% divided by 35%] times 1,000 = [0.0143] times 1,000 = 14.3
Therefore, dissolve 14.3 grams of calcium hypochlorite powder in one liter of water in order
to get a 0.5 percent chlorine solution.
Calculating the water to chlorine-releasing tablet ratio to make a 0.5

percent chlorine solution
Follow the manufacturer's instructions when using chlorine-releasing tablets because the
percentage of active chlorine in these products varies. If instructions are not available with
the tablets, ask for the product instruction sheet or contact the manufacturer. Table 5-229
provides details on how to mix a decontamination solution with chlorine.

Table 5-2. Mixing a 0.5 percent chlorine decontamination solution
Liquid bleach (sodium hypochlorite solution)
% or grams Water to chlorine =

Type or brand (by country)
active chlorine 0.5% solution
10 mL bleach in 40 mL water.
º
8 Chlorum* 2.4%
1 part bleach to 4 parts water.
JIK (Kenya, Zambia), Robin Bleach
3.5% 10 mL bleach in 60 mL water.
(Nepal)
º
12 Chlorum 3.6% 1 part bleach to 6 parts water.
Household Bleach (Indonesia, USA), 10 mL bleach in 90 mL water.

5%
ACE (Turkey), Eau de Javel (France) 1 part bleach to 9 parts water.
º
15 Chlorum, Lejia (Peru), 10 mL bleach in 110 mL water.
6%
Blanquedor, Cloro (Mexico) 1 part bleach to 11 parts water.
Lavandina (Bolivia) 8%
Chloros (United Kingdom) 10%
Chloros (United Kingdom), Extrait de 10 mL bleach in 290 mL water.
º 15%
Javel (France), 48 Chlorum 1 part bleach to 29 parts water.
Dry powders
Calcium hypochlorite 70% 7.1 grams per liter.
Calcium hypochlorite 35% 14.2 grams per liter.
Sodium dichloroisocyanurate (NaDCC) 60% 8.3 grams per liter.
Tablets
1 gram chlorine 20 grams per liter
Chloramine tablets*
per tablet. (20 tablets per liter).
1.5 grams
Sodium dichloroisocyanurate
chlorine per 4 tablets per liter.
(NaDCC-based tablets)
tablet.
*Chloramine releases chlorine slower than hypochlorite. Before using solution, be sure the tablet is completely
dissolved.



Summary
You have just reviewed principles of infection prevention in health care facilities. Applying
these principles rigorously will help protect yourself, your clients, and your community from
infection. You are the key to preventing infections in a health care facility!
Congratulations!
You have successfully completed the topic on infection prevention principles.
Your challenge is to evaluate how you and your colleagues are applying infection prevention
principles in the health care facility you are working in. If you notice that there are
differences between how infection prevention practices are applied in your facility and what
is recommended, work with your colleagues and manager to figure out why this is. Do you
have all of the equipment, materials, supplies, and consumables that you need? Does
everyone in the health care facility, including the sweepers, understand how and why to
apply infection prevention practices? After you have made an analysis with your colleagues
and manager, make a plan to improve how infection prevention practices are applied in your
facility.

Additional Topic 2: Birth preparedness and

complication readiness
Overview
When delays occur in recognizing problems and referring women to appropriate health care
facilities, the result can lead to maternal and newborn deaths. One solution to combat these
problems is to work with the pregnant woman and her family to develop two plans: a birth-
preparedness plan and a complication-readiness plan.33
Because all pregnancies carry risks, providers must work with all pregnant women and their
families to develop a birth-preparedness plan. This planning helps women receive high-
quality, timely care for both normal and complicated pregnancy, labor, and childbirth. The
following topic provides information on developing birth-preparedness and complication-
readiness plans.
Learning objectives
• Identify the components of the birth-preparedness plan and the
complication-readiness plan.
• Describe how these plans can prevent maternal and newborn deaths
Key definitions
Birth-preparedness plan (BPP): An action plan developed by a pregnant woman and her
family to prepare for the birth of her baby.
Danger sign: A sign or symptom indicating that a woman or newborn has a health problem
and should get medical care as soon as possible.
Complication-readiness plan (CRP): An action plan developed by pregnant and
postpartum women and their families to recognize and prepare to respond in case of a
complication.

Introduction
The risks associated with childbirth are a stark reality to most women in the
developing world. A Tanzanian saying goes: “….I am going to the other side
of the ocean to get my child. The trip is long and I don’t know if I will
return…” This sad declaration should push all of us to provide services that
will reduce maternal and newborn morbidity and mortality.
Because all pregnancies carry risk, providers must work with all
pregnant women and their families to develop a birth-preparedness
plan which will help ensure that women receive quality, timely care
for both normal and complicated pregnancy, labor, and childbirth.
The following session discusses how to develop a birth-preparedness
plan (BPP) and a complication-readiness plan (CRP).
Birth-preparedness plan (BPP)

Having a BPP can reduce delayed decision-making and increase the probability of timely
care. A BPP is an action plan made by the woman, her family members, and the health care
provider. Often this plan is not a written document, but instead is an ongoing discussion
between all concerned parties to ensure that the woman receives the best care in a timely
manner. Each family should have the opportunity to make a plan for the birth. Health care
providers can help the woman and her family to develop a BPP and discuss birth-related
issues. Work with the woman to:
Make plans for the birth:
Discuss the idea of a birth plan and what to include during the first visit.
Inquire about the BPP during the third or fourth antenatal visit.
Ask if arrangements are made for a skilled birth attendant and the birth setting
during the antenatal visit in the eighth month.
If planning a home delivery with a skilled birth attendant, discuss access to a safe
delivery kit consisting of 1) a piece of soap for cleaning the birth attendant’s hands
and the woman’s perineum, 2) a plastic sheet about one square meter for use as a
clean delivery surface, 3) clean string for tying the umbilical cord (usually two
pieces), and 4) a clean razor blade for cutting the cord.
Make birth-related decisions:
Where to give birth.
Who will be the skilled birth attendant.
How to contact the provider.
How to get to the place of birth.
Who will be the birth companion.
Who will take care of the family while the woman is absent.
How much money is needed and how to access these funds.

Prepare for the birth:

Discuss items needed for the birth (perineal pads/cloths, soap, clean bed sheets,
etc.) on the third antenatal visit.
Confirm necessary items are gathered near the due date.
Note: In some cultures, superstition surrounds buying items

for an unborn baby. If this is not the case, families can prepare
for the birth by buying baby supplies such as blankets, diapers,
and clothes.
Save money:
Discuss why and how to save money in preparation for the birth during the first visit.
Discuss how to plan to make sure that any funds needed are available at birth.
Check that the woman and her family have begun saving money or that they have
ways to access necessary funds.
Note: Encourage the family to save money so necessary funds

are available for routine care during pregnancy and birth.
Assess financial needs with the woman as well as sources for
accessing these funds so they are available before labor.

Delays resulting in maternal and newborn deaths
The factors that prevent women and newborns from getting the life-saving
health care they need include:
• Distance from health services.
• Cost (direct fees as well as the cost of transportation, drugs, and supplies).
• Multiple demands on women’s time.
• Women’s lack of decision-making power within the family.
• Poor-quality services, including poor treatment by health providers, which makes women
reluctant to use services.

These have been translated into the following delays:
• Delay in recognizing the problem: When a woman or newborn experiences a danger
sign, someone must recognize that there is a problem. If pregnant women, their
families, and women caring for them don’t know the danger signs that indicate the
woman or newborn is experiencing a complication, they will not know when they need to
seek care.
• Delay in deciding to seek care: When a problem arises, the woman and her family
have to decide to seek care. If the primary decision-maker is not present, it may mean
that the woman is not allowed to seek care or take her newborn for care, or seeking
care is delayed.
• Delay in arriving at the appropriate facility: Once a decision is made to seek care,
the woman and her family must finds a means of transport and the necessary funds to
go to the appropriate facility. If there is no means of transport and/or the woman and
her family do not have the necessary funds, the woman or newborn will not get to the
appropriate health care facility in a timely fashion.
• Delay in receiving quality care: Once the woman or newborn has reached the
appropriate level, care providers must provide quality services for whatever emergency
has transpired. If the care provided is not quality or appropriate care, then the woman
or newborn will have reached the appropriate facility in vain.
When delays occur in recognizing problems and referring women or newborns to appropriate
health care facilities, the result can lead to maternal and newborn deaths. One solution to
combat these problems is to work with the pregnant woman and her family to develop two
plans: a BPP and a CRP.

Complication-readiness plan (CRP)
The CRP is an action plan that outlines steps that can be discussed and determined prior to
an emergency. Developing this plan helps the family to be prepared for and respond quickly
when the woman or newborn has a complication and needs medical care. It is important
that a CRP is prepared with the woman and her chosen family members. Unless others are
involved, the woman may have difficulties putting the plan into action should complications
occur for her or her baby.

Recognize danger signs

Women, family members, and community caregivers must know the signs of life-
threatening complications. Many hours can be lost from the time a complication is
recognized until the time arrangements are made for the woman to reach help. For PPH, the
time from the start of bleeding to death can be as little as two hours. In too many cases,
families of women who died in pregnancy, birth, or postpartum did not recognize the
problem in time. It is critical to reduce the time needed to recognize problems and make
arrangements to receive care at the most appropriate level. Women, family members, and
community caregivers must know the signs of life-threatening complications.
Maternal danger signs include:

Vaginal bleeding (any vaginal bleeding during pregnancy; heavy vaginal bleeding or
a sudden increase in vaginal bleeding during the postpartum period).
Breathing difficulties.
Fever.
Severe abdominal pain.
Severe headache/blurred vision.
Convulsions or loss of consciousness.
Foul-smelling discharge from vagina, tears, and incisions.
Calf pain with or without swelling.
Night blindness.
Verbalization or behavior indicating she may hurt the baby or herself.
Hallucinations.
Newborn danger signs include:

Breathing problems.
Feeding difficulties or not sucking.
Feels cold or has fever.
Redness, swelling, or pus from eyes or around the cord or umbilicus.
Convulsions or fits.
Jaundice (yellow skin).
Save money
Similar to the BPP, the family should be encouraged to save money so necessary funds are
available for emergencies. In many situations, women either do not seek or receive care
because they lack funding to pay for services.
Choose a decision-maker in case of emergency

In many families, one person is the primary decision-maker. Too often, other members of
the family do not feel they can make decisions if that person is absent. This can result in
death when an emergency occurs and the primary decision-maker is absent. It is important
to discuss how the family can make emergency decisions without disrupting or offending
cultural and family values. If possible, find out which family member can make a decision in
the absence of the chief decision-maker.

Have an emergency transportation plan
Too many women and newborns die because they suffer serious complications and do not
have access to transportation to the type of health care facility that can provide needed
care. Each family should develop a transportation plan during the woman’s early pregnancy
in case the woman experiences complications and urgently needs a higher level of care. This
plan should be prepared during pregnancy and after giving birth, either before discharge
from the health facility or immediately after returning home. The plan should address the
following:
Where to go if complications arise.
How to get to the next level of care in case of an emergency.
Who in the family will accompany the woman.
Have an emergency blood donation plan

Many health care facilities lack an adequate, safe blood supply for transfusions. After
birth, women are more likely to need blood transfusions because the complications they
experience from birth lead to blood loss. For these reasons, it is extremely important
that the woman and her family determine blood donors that can be available if needed.


Summary
You have just reviewed the elements of birth preparedness and complication readiness
plans. Every woman who receives antenatal care at your facility should be assisted to
develop a BPP and CRP with her husband and other members of her family. Every woman
who gives birth in your facility should be assisted to develop a CRP with her husband and
other members of her family before leaving the facility. Wherever possible, community
health workers should work to educate all community members about dangers signs during
pregnancy, labor, the postpartum, and in the newborn. If women and babies can seek help
in a timely manner, they are more likely to survive whatever problem they are
encountering.
Congratulations!
You have successfully completed the topic on birth preparedness and complication
readiness.
Your challenge is to evaluate how you and your colleagues are assisting women and their
families to prepare for birth during antenatal care and to make a CRP before they leave the
facility after giving birth. If you notice that your colleagues are not helping women and their
families prepare BPPs and CRPs, work with your colleagues and manager to figure out why
this is. Do your colleagues know how and why to help women and their families develop
these plans? Do your colleagues feel that they don’t have enough time to assist women and
families develop these plans? Are women in the community superstitious about preparing
for the birth? After you have made an analysis with your colleagues and manager, make a
plan to improve how providers in your facility assist women and their families prepare BPPs
and CRPs.

Additional topic 3: Managing complications during

the third stage of labor
Overview
When correctly performed, AMTSL can minimize problems and complications. However,
problems may occur regardless of how the third stage of labor is managed. When
emergencies arise, providers must recognize and manage them promptly. This section
provides guidance on how to provide the initial emergency management for some of the
most common problems associated with the third stage of labor.
Research shows that AMTSL does not increase the risk for obstetrical complications;
however, problems may happen regardless of how the third stage is managed. The WHO
publication “Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and
Doctors” provides the following guidelines for immediate management of complications
during the third stage of labor.34 Follow local guidelines for managing any complications and
referring a woman for further treatment during or after the third stage of labor. For detailed
information on clinical management, consult technical resources (www.pphprevention.org)
or a supervisor.
Learning objectives
By the end of this topic, participants will be able to describe the immediate medical
management of the following complications that may occur during the third stage of labor:
• Excessive bleeding after childbirth.
• Shock.
• Uterine atony (uterus does not adequately contract)
• Genital lacerations.
• Cervical tears.
• Retained placenta.
• Ruptured cord tears (cord tears during CCT).
Key definitions
Shock: A serious, often life-threatening medical condition where insufficient blood flow
reaches the body tissues.

General management for an obstetric emergency
Emergencies can happen suddenly, as with a convulsion, or they can

develop as a result of a complication that is not properly managed or monitored.
Preventing emergencies
Most emergencies can be prevented by:
• Careful planning.
• Following clinical guidelines.
• Closely monitoring the woman.
Responding to an emergency
Responding to an emergency promptly and effectively requires that members of the clinical
team know their roles and how the team should function to respond most effectively to
emergencies. Team members should also know:
• Clinical situations and their diagnoses and treatments.
• Drugs and their use, administration and side effects.
• Emergency equipment and how it functions.
Note: The ability of a facility to deal with emergencies should

be assessed and reinforced by frequent practice emergency
drills.
Initial management
In managing an emergency:
• Stay calm. Think logically and focus on the needs of the woman.
• Do not leave the woman unattended.
• Take charge. Avoid confusion by having one person in charge.
• SHOUT FOR HELP. Have one person go for help and have another person gather
emergency equipment and supplies (e.g., oxygen cylinder, emergency kit).
• If the woman is unconscious, assess the airway, breathing and circulation.
• If shock is suspected, immediately begin treatment. Even if signs of shock are not
present, keep shock in mind as you evaluate the woman further because her status
may worsen rapidly. If shock develops, it is important to begin treatment
immediately.
• Position the woman lying down on her left side with her feet elevated. Loosen tight
clothing.
• Talk to the woman and help her to stay calm. Ask what happened and what
symptoms she is experiencing.
• Perform a quick examination including vital signs (blood pressure, pulse, respiration,
temperature) and skin color.
• Estimate the amount of blood lost and assess symptoms and signs.

Job Aid: Managing obstetric emergencies
Shout for help!

Urgently mobilize all available personnel.
Rapidly evaluate vital signs (pulse, blood pressure, respiration, and

temperature).
Start an IV infusion (two, if possible) using a large-bore (16-

gauge or largest available) cannula or needle. Collect blood
just before infusion of fluids. Rapidly infuse IV fluids.
Begin specific evaluation and management

for the obstetric emergency.

General management for shock
Signs and symptoms usually seen in shock:
Fast, weak pulse (110 beats per minute or more).
Low blood pressure (systolic less than 90 mm Hg).
Other signs and symptoms of shock include:
Pallor (especially of inner eyelids, palms, or around the mouth).
Sweaty or cold, clammy skin.
Rapid breathing (rate of 30 breaths per minute or more).
Anxiousness, confusion, or unconsciousness.
Low urine output (less than 30 mL per hour).
Immediate management of shock

Shout for help. Urgently mobilize all available personnel.
Evaluate vital signs (pulse, blood pressure, respiration, temperature).
Turn the woman onto her side to reduce the risk of aspiration from vomiting and to
ensure an open airway.
Keep the woman warm; however, avoid overheating, which increases peripheral
circulation and reduces blood supply to the vital organs.
Elevate the legs to increase return of blood to the heart (if possible, raise the foot
end of the bed).
Specific management
Start an IV infusion (or two if possible) using a large-bore cannula or needle (16
gauge or largest available).
Collect blood to test hemoglobin; do an immediate cross-match and bedside clotting
(see below) before infusion of fluids:
− Rapidly infuse IV fluids (normal saline or Ringer’s lactate) initially at the
rate of 1 L in 15 to 20 minutes.
Note: Avoid using plasma substitutes (e.g., dextran) because

there is no evidence that plasma substitutes are superior to
normal saline in resuscitating a shocked woman. Also, dextran
can be harmful in large doses.
− Give at least 2 L of these fluids in the first hour. (This amount is in

addition to fluids given for lost blood.)
Note: Do not give fluids by mouth to a woman in shock. A

quicker rate of infusion is needed in the management of shock
from bleeding. Aim to replace 2 to 3 times the estimated fluid
loss.
When finding a peripheral vein is not possible, do a venous cut-down.

Continue to monitor vital signs and blood loss (every 15 minutes).

Catheterize the bladder and monitor fluid intake and urine output.
If available, give oxygen at 6 to 8 L per minute by mask or nasal cannula.
Bedside clotting test

Assess blood clotting status using this bedside clotting test:
1. Take 2 mL of venous blood into a small, dry, clean, plain glass test-tube
(approximately 10 mm x 75 mm).
2. Hold the tube in your closed fist to keep it warm (+37°C).
3. After four minutes, tip the tube slowly to see if a clot is forming. Then tip it again
every minute until the blood clots and the tube can be turned upside down.
4. If a clot does not form after seven minutes or a soft clot forms that breaks down
easily, the woman may have a blood clotting disorder.
Decide and manage the cause of shock

After the woman is stabilized, determine the cause of shock and manage the condition
accordingly.

Job Aid: Managing shock
Shout for help!

Rapidly evaluate vital signs (pulse, blood pressure, respiration, and

temperature).
Turn the woman onto her side.
Keep the woman warm but do not

overheat.
Elevate the legs.
Start an IV infusion (two if possible). Collect blood just

before infusion of fluids. Rapidly infuse fluids.
Catheterize the bladder and monitor fluid

intake and urine output.
If available, give oxygen at 6–8 L per minute by mask or nasal

cannulae.
Continue to monitor vital signs (every 15 minutes) and

blood loss.
Determine the cause of shock and begin treatment.

Learning activity 7.1 (Estimated time to complete this activity: 15

minutes)
General management for vaginal bleeding after

childbirth
Excessive vaginal bleeding is life-threatening and requires immediate action.
Follow these steps to manage excessive bleeding:
Note: The steps listed here are only a summary and do not
include extensive details about PPH management. Refer to local
protocols or a technical reference for detailed management.
Shout for help. Urgently mobilize all available personnel.

Conduct a rapid evaluation of the woman’s general condition including vital signs
(pulse, blood pressure, respiration, temperature).
If shock is suspected, immediately begin treatment. If signs of shock are not
present, continue evaluating the woman because her status can change or worsen
rapidly.
Massage the uterus to expel blood and blood clots. Blood clots trapped in the uterus
will prevent effective uterine contractions.
Give oxytocin 10 IU IM.
Start an IV infusion.
Just before infusion of fluids, collect blood to test hemoglobin, and do an immediate
cross-match and bedside clotting (see below).
If blood is available for transfusion, prepare blood (type and cross) before beginning
infusion.
Have the woman empty her bladder or ensure that the bladder is empty (catheterize
the bladder only if necessary).
Check to see if the placenta is expelled, and examine it for completeness.
Examine the vagina and perineum for tears (examination of the cervix is only
warranted if the uterus is firm, the placenta and membranes are complete, no
perineal or vaginal lacerations are present, but the woman continues to bleed).
Provide specific treatment for the cause of PPH (see Table 8).

Job Aid: Managing vaginal bleeding after childbirth
Shout for help!

Make a rapid evaluation of the general condition of the

woman, including vital signs (pulse, blood pressure,
respiration, temperature).
If shock is suspected, immediately begin treatment. Keep

shock in mind even if there are no signs present.
Massage the uterus to expel blood and blood clots.
Start an IV infusion. Collect blood just before infusion

of fluids. Infuse IV fluids.
Help the woman empty her bladder.
Check to see if the placenta is expelled, and examine the

placenta for completeness. Examine the vagina, perineum,
and cervix for tears.
Determine the cause of bleeding and begin treatment.


Diagnosis of vaginal bleeding after childbirth
Although the presentation of PPH is most often dramatic, bleeding may be slower and
seemingly less noteworthy but may still ultimately result in critical loss and shock. This is
more likely to be true of bleeding secondary to retained tissue or trauma.
The usual presentation of PPH is one of heavy vaginal bleeding that can quickly lead to signs
and symptoms of hypovolemic shock. This rapid blood loss reflects the combination of high
uterine blood flow and the most common cause of PPH, i.e., uterine atony. Blood loss is
usually visible at the introitus, and this is especially true if the placenta has delivered. If the
placenta remains in situ, then a significant amount of blood can be retained in the uterus
behind a partially separated placenta, the membranes, or both.
Rapid recognition and diagnosis of PPH is essential to successful management. Resuscitative
measures and the diagnosis and treatment of the underlying cause must occur quickly
before sequelae of severe hypovolemia develop. The major factor in the adverse outcomes
associated with severe hemorrhage is a delay in initiating appropriate management. Table
7-132 provides an overview for diagnosing the cause of vaginal bleeding after childbirth.
Table 7-1. Diagnosis of vaginal bleeding after childbirth
Presenting symptom
and other symptoms Symptoms and signs
Probable diagnosis
and signs typically sometimes present
present
• Immediate PPHa
• Uterus soft and not • Shock Atonic uterus
contracted
• Immediate PPHa • Complete placenta Tears of cervix, vagina or
• Uterus contracted perineum
• Placenta not delivered
• Immediate PPHa
within 30 minutes after Retained placenta
• Uterus contracted
delivery of baby
• Portion of maternal
surface of placenta • Immediate PPHa Retained placental
missing or torn • Uterus contracted fragments
membranes with vessels
• Uterine fundus not felt • Inverted uterus apparent Inverted uterus
on abdominal palpation at vulva
• Slight or intense pain • Immediate PPHb
a
Bleeding may be light if a clot blocks the cervix or if the woman is lying on her back.
b
There may be no bleeding with complete inversion.

Job aid: Specific management for PPH
• Immediate PPH. • Immediate PPH. • Immediate PPH

• Uterus soft and not • Complete placenta. • Placenta not delivered
contracted. • Uterus contracted. within 30 minutes after
delivery of baby.
• Portion of maternal
surface of placenta
Uterine atony missing or torn
Genital tears membranes with vessels.
• Uterus contracted.
• Continue to massage
the uterus. Retained placenta/
• Administer uterotonic placental fragments
drugs, given together • Examine the woman
or sequentially. carefully and repair tears
to the vagina and
• Ensure the bladder is perineum. • If the placenta is visible, ask
empty. the woman to squat and push.
• If vaginal and perineal
• Anticipate the need for tears are absent or • If you can feel the placenta in
blood as soon as repaired and bleeding the vagina, remove it.
possible, and transfuse continues, examine the • Help the woman empty her
as necessary. placenta again for bladder.
• If bleeding persists: completeness.
• If the placenta is not expelled,
- Check placenta again • If the placenta is give oxytocin 10 IU IM (if not
for completeness. complete, inspect the already administered for
- If there are signs of cervix. AMTSL).
retained placental • If bleeding continues, • If the placenta is undelivered
fragments, remove assess clotting status after 30 minutes of oxytocin
remaining placental using a bedside clotting stimulation and the uterus is
tissue. test. contracted, attempt CCT with
- Assess blood clotting countertraction to the uterus.
status using this • If CCT is unsuccessful,
bedside clotting test. attempt manual removal of
• If bleeding persists in the placenta.
spite of above • If bleeding continues, assess
management: clotting status using a bedside
- Perform internal clotting test.
bimanual • If there are signs of infection
compression of the (fever, foul-smelling vaginal
uterus. discharge), administer
- Alternatively, antibiotics as for metritis.
compress the aorta.
- Maintain pressure
until bleeding has
stopped or the
woman has access to
surgical intervention.

Learning activity 7.3 (Estimated time to complete this activity:

15 minutes)
Management of uterine atony
An atonic uterus fails to contract after delivery.
Signs and symptoms usually seen in cases of uterine atony:

Immediate PPH.
Bleeding may be light if a clot blocks the cervix or if the woman is
lying on her back.
Uterus is soft and does not contract.
Signs and symptoms sometimes present:
Shock.
Immediate management of atonic uterus

If the woman is bleeding and her uterus is soft/not contracted:
Continue to massage the uterus.
Have the woman empty her bladder or ensure that the bladder is empty (catheterize
the bladder only if necessary).
Administer uterotonic drugs, given together or sequentially (Table 7-2)32.
Anticipate the need for blood as soon as possible, and transfuse as necessary.
Table 7-2. Uterotonic drugs for PPH management
Oxytocin Ergometrine Misoprostol

IV: Infuse 20 units in 1
Dose and L IV fluids at 60 drops
IM: give 0.2 mg. 1,000 mcg rectally.
route per minute.
IM: 10 IU.
Repeat 0.2 mg IM after
IV: Infuse 20 units in 1
Continuing 15 minutes.
L IV fluids at 40 drops Unknown.
dose If required, give 0.2 mg
per minute.
IM every 4 hours.

Oxytocin Ergometrine Misoprostol
Oral dose should not
Not more than 3 L of IV exceed 600 mcg
Maximum fluids containing because of side
5 doses (total 1.0 mg).
dose oxytocin. effects of increased
temperature and
chills.
Contraindicated in
Precautions After 2–3 doses with no
cases of pre-eclampsia, Contraindicated in
and result, use alternate
hypertension, heart cases of asthma.
comments treatment.
disease.
If bleeding continues:
Check placenta again for completeness.
If there are signs of retained placental fragments (absence of a portion of
maternal surface or torn membranes with vessels), remove remaining placental
tissue.
Assess clotting status using a bedside clotting test. If a clot does not form after
seven minutes or a soft clot forms that breaks down easily, the woman may have a
blood clotting disorder.
If bleeding continues in spite of management, perform bimanual compression of the
uterus (Figure 7-1):
1. Wearing sterile or HLD gloves, insert a hand into

the vagina and form a fist.
2. Place the fist into the anterior fornix and apply
pressure against the anterior wall of the uterus.
3. With the other hand, press deeply into the
abdomen behind the uterus, applying pressure
against the posterior wall of the uterus.
4. Maintain compression until bleeding is controlled
and the uterus contracts.
Figure 7-1. Bimanual compression

of the uterus. (WHO, 2003)
Alternatively, compress the aorta and prepare for potential surgical management (Figure 7-
2):
1. Apply downward pressure with a closed fist over the abdominal aorta
directly through the abdominal wall (the point of compression is just
above the umbilicus and slightly to the left):
− Aortic pulsations are felt easily through the anterior abdominal wall
in the immediate postpartum period.

2. With the other hand, feel the femoral pulse to check the adequacy of
compression:
− If the femoral pulse is felt during compression, the pressure exerted

by the fist is inadequate.
− If the femoral pulse is not felt, the pressure exerted is adequate.

3. Maintain compression until bleeding is controlled.
Figure 7-2. Compression of abdominal aorta and

feeling the femoral pulse. (WHO, 2003)
Note: Packing the uterus is ineffective and wastes precious

time.
When bleeding continues in spite of compression, the woman may require surgical
intervention.


Management of tears in the birth canal
Tears of the birth canal are the second most common cause of PPH. Tears
may be present at the same time as uterine atony.
Signs and symptoms usually seen with genital tears:

Immediate PPH (bleeding may be light if a clot blocks the cervix or if the
woman is lying on her back).
Complete placenta.
Uterus contracted.
Signs and symptoms sometimes seen:
Shock.
Postpartum bleeding with a contracted uterus is usually due to a cervical or vaginal tear.
Examine the woman carefully and repair tears to the vagina and perineum.
If vaginal and perineal tears are absent or repaired and bleeding continues, examine
the placenta again for completeness.
If the placenta is complete, inspect the cervix.
− Ask your assistant to press firmly down on the uterus. This moves the
cervix lower in the vagina for careful examination. Good lighting may
help facilitate the exam.
− Look carefully at all sides of the cervix for oozing

or spurts of blood. Lacerations occur most
frequently on the sides (9 and 3 o’clock positions)
of the cervix (Figure 7-3).
− If you are unable to see the entire cervix due to

bleeding, use two sponge forceps to “walk” around
the cervix to inspect it completely. Put the first
forceps at the 12 o’clock position and the second
forceps at 2 o’clock position on the cervix. Hold the
handles from both forceps in one hand.
Figure 7-3. Common positions
for cervical tears. (Marshall et
al., 2007)
− To see the laceration better, pull the forceps handles toward you. Look
for tears. Release the first forceps and place it on the cervix at 4
o’clock. Pull the forceps handles toward you and look for tears. Follow
counter-clockwise in this manner until the entire cervix has been
inspected.

− Repair lacerations by
placing interrupted or
continuous sutures the
length of the tear,
spaced about 1 cm apart
using 0-chromic or
polyglycolic sutures
(Figure 7-4).
Figure 7-4. Repairing a cervical tear. (WHO, 2003)
• If bleeding continues, assess clotting status using a bedside clotting test. If a clot
does not form after seven minutes or a soft clot forms that breaks down easily, the
woman may have a blood clotting disorder.


Management of retained placenta
A retained placenta means that all or part of the placenta or membranes is
left behind in the uterus during the third stage of labor. Normally, after the
placenta is delivered, the empty uterus contracts down to close off all the
blood vessels inside the uterus. If the placenta only partially separates, the
uterus cannot contract properly, so the blood vessels inside will continue to bleed.
Signs and symptoms usually present with a retained placenta:

Placenta not delivered within 30 minutes of delivery of baby.
Signs and symptoms sometimes seen:
Immediate PPH (Bleeding may be light if a clot blocks the cervix or if the
Shock.
Note: There may be no bleeding with a retained placenta.
If you can see the placenta, ask the woman to squat and push.
If you can feel the placenta in the vagina, remove it.
Sometimes a full bladder will hinder delivery of the placenta. Help the woman empty
her bladder (catheterize the bladder only if necessary).
If the placenta is not expelled, give oxytocin 10 IU IM (if not already administered
for AMTSL).
Note: Do not give ergometrine for a retained placenta because

it causes tonic uterine contraction, which may delay expulsion.
If the placenta is undelivered after 30 minutes of oxytocin stimulation and

the uterus is contracted, attempt CCT with countertraction to the uterus.
Note: Avoid forceful cord traction and fundal pressure because

these interventions may cause uterine inversion.
If CCT is unsuccessful and the attendant is adequately trained to perform manual

removal, attempt manual removal of the placenta and administer a single dose of
prophylactic antibiotics: ampicillin 2 g IV PLUS metronidazole 500 mg IV or cefazolin
1 g IV PLUS metronidazole 500 mg IV.
Caution: Very adherent tissue may be placenta accreta. Efforts

to extract a placenta that does not separate easily may result in
heavy bleeding or uterine perforation, which usually requires a
hysterectomy.
If bleeding continues, assess clotting status using a bedside clotting test. If a clot

If there are signs of infection (fever, foul-smelling vaginal discharge), administer

antibiotics as for metritis.
Note: In low-resource settings, do not attempt manual removal

of the placenta unless the woman is bleeding. If she is not
bleeding, refer her to a higher level of care.
Management of retained placental fragments

If a portion of the placenta—one or more lobes—is retained, it prevents the uterus from
contracting effectively and can cause PPH. If small fragments of placenta or membrane
are retained and are not detected immediately, this may cause heavy bleeding and
infection later on.
Signs and symptoms usually present with retained placental

fragments:
A portion of maternal surface of placenta is missing or torn.
Immediate PPH (bleeding may be light if a clot blocks the cervix or if the
Note: There may be no bleeding with retained placental fragments.
Wearing sterile or HLD gloves, perform manual exploration of the uterus for placental
fragments. Manual exploration of the uterus is similar to the technique described for
removal of the retained placenta. Give prophylactic antibiotics according to local
protocols.
Caution: Only providers trained to perform manual exploration

of the uterus should attempt to do so.
Remove placental fragments by hand, or with ovum forceps or large curette.
Caution: Very adherent tissue may be placenta accreta. Efforts

to extract fragments that do not separate easily may result in
heavy bleeding or uterine perforation, which usually requires a
hysterectomy.


Management of uterine inversion
The uterus is inverted if it turns inside out during delivery of the placenta.
This is very rare during a normal third stage of labor, whether managed
actively or physiologically.
Signs and symptoms usually seen with an inverted uterus:

Uterine fundus not felt on abdominal palpation.
Slight or intense pain.
Inverted uterus apparent at vulva.
Immediate PPH (there may be no bleeding with complete inversion).
Reposition the uterus immediately. As time passes, the uterus becomes more
engorged with blood and is more difficult to put back into place.
If the woman is in severe pain, give pethidine 1 mg/kg body weight (but not more
than 100 mg) IM or IV slowly or give morphine 0.1 mg/kg body weight IM.
Caution: Do not give uterotonic drugs until the inversion is

corrected.
Support the uterus with your non-dominant hand and reposition the uterus with your
dominant hand (Figure 7-543).
Note: If the placenta has not separated from the uterine wall
when inversion occurs, do not attempt removal of the placenta
until the inversion is corrected.
Figure 7-5. Manual

reduction of an inverted
uterus. (WHO, 2003)

Administer a single dose of prophylactic antibiotics after correcting the inverted

uterus: ampicillin 2 g IV plus metronidazole 500 mg IV, or cefazolin 1 g IV plus
metronidazole 500 mg IV.
If there are signs of infection (fever, foul-smelling vaginal discharge), give antibiotics
as for metritis.
Management if the cord tears off during CCT

In many studies and experience with thousands of women, cord tears were not reported as
a significant problem during AMTSL. In the rare event this happens:
Have the woman empty her bladder (catheterize the bladder only if necessary).
If the placenta has separated, ask the woman to squat and push with a contraction.
If the placenta has not separated, the woman is not bleeding, and the provider has
appropriate training, consider performing manual removal of the placenta.
Otherwise, refer the woman to a higher level of care.


Summary
You have reviewed the most important steps in immediate management of the most
common causes of PPH. The woman’s prognosis depends upon your ability to correctly and
rapidly diagnose and manage the cause of her PPH. You can make the difference between a
woman living or dying when she has a PPH.
Congratulations!
You have successfully completed the topic on initial management of selected obstetric
emergencies.
Your challenge is to evaluate how you and your colleagues manage the care of women who
have PPH. If you notice that your colleagues are not following recommended guidelines for
initial assessment and management of vaginal bleeding after childbirth, work with your
colleagues and manager to figure out why this is. Do your colleagues have a reason for how
they are managing vaginal bleeding after childbirth? Have your colleagues recently had an
update in management of obstetric emergencies? Do you have all of the equipment,
materials, consumables, and medications needed to effectively manage vaginal bleeding
after childbirth? After you have made an analysis with your colleagues and manager, make
a plan to improve how providers in your facility manage vaginal bleeding after childbirth.

Suggested answers to learning activities
Core Topic 1: Third stage of labor and evidence for using

AMTSL
Learning activity 1.1
1. Reflect on how the third stage of labor is managed at the health care facility where you
work. Analyze each step of the third stage of labor management and decide whether the
step is part of active management of the third stage of labor (AMTSL) or physiologic
management of the third stage of labor (PMTSL). If the step is part of PMTSL, write the
step in the column with that title; if the step is part of AMTSL, write the step in the
column with that title.
Physiologic management of the third Active management of the third stage
stage of labor of labor
Uterotonic is given within one minute of the
Uterotonic is not given before the placenta
baby’s birth (after ruling out the presence of
delivered.
a second baby).
Wait for signs of separation: Do not wait for signs of placental separation.
Gush of blood. Instead:
Lengthening of cord. Palpate the uterus for a contraction.
Uterus becomes rounder and smaller as Wait for the uterus to contract.
the placenta descends. Apply CCT with countertraction.
Placenta delivered by CCT while supporting
Placenta delivered by gravity assisted by
and stabilizing the uterus by applying
maternal effort.
countertraction.
Massage the uterus after the placenta is Massage the uterus after the placenta is
delivered. delivered.
2. Read each sentence below describing an element of active or physiologic management of

the third stage of labor. Note the type of management described and write AMTSL,
PMTSL, or both in the corresponding column.
Actions used to manage the third stage of Type of management

labor (AMTSL, PMTSL, or both)
Example: The provider administers uterotonic
PMTSL
drugs only after delivery of the placenta.
a. The provider delivers the placenta using
controlled cord traction with AMTSL
countertraction to support the uterus.
b. The provider massages the uterus
AMTSL/PMTSL
immediately after delivery of the placenta.
c. The provider waits for signs of placental
PMTSL
separation.
d. A uterotonic is administered within
AMTSL
one minute of the baby’s birth.
e. The placenta is delivered with the
PMTSL
assistance of gravity and maternal effort.

1. AMTSL and PMTSL provide different advantages. Read each sentence below describing a
result of managing the third stage of labor, and place an “X” in the column of the
management type that best describes the advantage.
Advantage AMTSL PMTSL

Example: Decreases length of the third stage. X
a. Does not interfere with normal labor

process. X
b. Decreases the number of cases of

PPH. X
c. Decreases average blood loss. X
d. Decreases need for blood transfusion. X
e. Does not require special drugs or supplies. X
2. Reflect on the scientific research that has been conducted to evaluate AMTSL, look at the
advantages and disadvantages of each way to manage the third stage of labor, and then
write a short essay on the type of third-stage management, active or physiologic, that
you feel should be promoted at your health care facility.

Core Topic 2: Prevention of postpartum hemorrhage

True or False
In the space provided, write “T” for true or “F” for false for each statement.
False 1. Nearly half of women who deliver vaginally will lose blood in excess of 1,000 mL.
True 2. Women who give birth by cesarean operation normally lose 1,000 mL of blood or
more.
True 3. For severely anemic women, blood loss of even 200 to 250 mL can be fatal.
False 4. Nearly two-thirds of women who have PPH have risk factors that help providers
predict a PPH.
Short answer
Write a brief response to the question in the space provided.
3. Explain why it may be useful to define PPH as “any amount of bleeding that causes
deterioration of the woman’s condition.”
• It is difficult to measure blood loss accurately.
• Research has shown that blood loss is frequently underestimated.
• Nearly half of women who deliver vaginally often lose at least 500 mL of blood.
• For severely anemic women, blood loss of even 200 to 250 mL can be fatal.
4. What is the most common cause of severe PPH in the first 24 hours after birth?
• Uterine atony.

1. What are the three most common causes of PPH?
• Uterine atony.
• Lacerations in the birth canal.
• Retained placenta or placental fragments.
2. Explain why a woman bleeds vaginally after childbirth when her uterus does not contract
adequately.
• Contractions of the uterine muscle fibers help to compress maternal blood vessels.
Bleeding may continue from the placental site if contractions are not adequate.
3. Which of the factors contributing to uterine atony can be reduced by the provision of
quality care during labor and childbirth?
• Full bladder.
• Prolonged or obstructed labor.
• Augmentation of labor.
• Induction of labor.

True or False
True 1. If PPH does occur, having a low hemoglobin level will reduce the woman’s chance
of surviving it.
True 2. Cervical examination is recommended only when the cause of PPH has not been
diagnosed and uterine atony, lower genital lacerations, and retained placenta are
ruled out.
True 3. Prevention of anemia during pregnancy can improve the woman’s chance of
surviving if she has a PPH.
True 4. Using a partogram to monitor and guide management of labor and detect
unsatisfactory progress of labor in a timely fashion may be useful in preventing
PPH.
False 5. Women are unable to monitor the firmness of their own uterus.
Short answer
Write a brief response to the question in the space provided.
1. Explain why a strategy to prevent PPH should not be based on identifying risk
factors.
• Up to two-thirds of women who have PPH have no risk factors
2. Describe a prevention strategy for each of the factors listed in the first column that
may contribute to the loss of uterine muscle tone in the postpartum period.
Factors contributing to the loss

Prevention strategy
of uterine muscle tone
• Encourage/assist women to empty their bladder during
labor and before second stage.
Full bladder
• Encourage/assist women to empty their bladder
regularly in the immediate postpartum period.
• Give birth with a skilled provider.
• Monitor labor using the partograph.
Prolonged/obstructed labor • Transfer women to a facility with cesarean facilities
once unsatisfactory progress in labor has been
identified.
• Give birth with a skilled provider.
• Monitor labor using the partograph.
• Only augment or induce labor when there are clear
medical or obstetric indications.
Oxytocin induction or augmentation • Only augment or induce labor in a health facility where
of labor personnel are trained to monitor the woman and fetus
and where cesarean operation can be performed if
necessary.
• Never give oxytocin intramuscularly in the antepartum.
• If using misoprostol, only use 25 mcg tablets.

Core Topic 3a: Review of uterotonic drugs

1. Explain how improper use of uterotonics can result in grave risks to the woman
and fetus, including umbilical cord compression, uterine rupture, and uterine fatigue
after childbirth (associated with uterine atony and PPH).
Improper use of uterotonics results in grave risks for the woman because:
• Unusually strong uterine contractions may cause umbilical cord compression and
subsequent decrease in the baby's oxygen supply (occurs with the increased
pressure of contractions).
• Unusually strong uterine contractions may result in uterine rupture or early
separation of the placenta from the uterine wall (abruptio placentae).
• Unusually strong uterine contractions may cause increased pain of the uterotonic-
induced contractions, which will likely increase the woman’s stress and anxiety
levels.
• Water intoxication may result when oxytocin—a strong anti-diuretic, even at low
doses—is combined with intravenous (IV) fluids.
• Uterine fatigue may result after childbirth (associated with uterine atony and PPH).
2. List three conditions that will influence whether labor should be augmented with
uterotonic drugs.
Labor should be augmented only if:
• Clear emergency or obstetric conditions are present, and
• Health care personnel familiar with the effects of uterotonics and able to identify
both maternal and fetal complications are present, and
• A physician is readily available to perform a cesarean delivery should complications
arise.

1. Make a list of uterotonic drugs used in your practice. Write the name you are
accustomed to using in either the column “trade name” or “generic name.”
2. If you have listed a uterotonic by the trade name, try to find the generic name, and vice
versa.
Trade name Generic name

Syntocinon®/Pitocin Oxytocin
Methergine® Ergometrine
Syntometrine® Ergometrine + Oxytocin
Misoprostol (Cytotec®) E1 analog prostaglandin

3. Compare oxytocin, misoprostol, and ergometrine. Use the chart below to
document various characteristics and qualities of these drugs.
Quality or
Oxytocin Misoprostol Ergometrine
characteristic
Shivering and Nausea, vomiting,

Minimal or no
Side effects elevated headaches, and
side effects.
temperature. hypertension.
Contraindicated in
women with a history of
No known No known
Contraindications hypertension, heart
contraindications contraindications
during the disease, retained
for postpartum for postpartum
postpartum period placenta, pre-
use. use.
eclampsia, or
eclampsia.
Causes tonic
Risks for retained contractions (may
N/A N/A
placenta increase risk of retained
placenta).
4. Review the information comparing the three main uterotonic drugs: oxytocin,
ergometrine, and misoprostol. Read the characteristics listed below and place an
“X” in the column corresponding to the uterotonic drug that best fits each
characteristic.
Ergometrine
Misoprostol
Uterotonic drug characteristic Oxytocin
Example: Works the fastest. X
o Longest acting. X
o Causes tonic contractions. X
o Common side effects include shivering and elevated

X
temperature.
o Common side effects include headache. X
o Is contraindicated in women with or having history of

hypertension, heart disease, retained placenta, pre- X
eclampsia, or eclampsia.
o Has no contraindications when administered in the

X X
postpartum period.

5. Based on your knowledge of the onset of action, duration of action, side effects,
and contraindications, which of the uterotonic drugs is preferred for AMTSL?
Oxytocin is the uterotonic drug of choice. Oxytocin is fast-acting, inexpensive and in
most cases has no side effects or contraindications for use during the third stage of
labor. It is also more stable than ergometrine in hot climates and light if cold/dark
storage is not possible.
1. Describe how to decide which uterotonic drug to use for AMTSL if your health care
facility has a stock-out of oxytocin.
In the context of active management of the third stage of labor, if oxytocin is not
available but other injectable uterotonics are available:
• Skilled attendants should offer ergometrine/methylergometrine or the fixed drug
combination of oxytocin and ergometrine to women without hypertension or heart
disease for prevention of PPH.
• Skilled attendants should offer 600 micrograms (mcg) misoprostol orally to women
with hypertension or heart disease for prevention of PPH.
To help prevent PPH, if injectable uterotonics are not available, misoprostol should be
administered soon after the birth of the baby.
2. Describe how you will manage the third stage of labor if there are no injectable
uterotonic drugs available.
To help prevent PPH, if injectable uterotonics are not available, misoprostol should be
administered soon after the birth of the baby. The usual components of giving
misoprostol include:
• Administration of 600 micrograms (mcg) misoprostol orally after the birth of the
baby
3. Describe how the third stage of labor should be managed if a skilled birth attendant is
not available.
In the context of prevention of PPH, if the birth attendants’ skills are limited, misoprostol
or oxytocin should be administered soon after the birth of the baby.
• Administration of 600 micrograms (mcg) misoprostol orally or oxytocin 10 IU IM
after the birth of the baby
Note: CCT should be performed only by a skilled birth attendant who has been trained to
do it.
4. Describe how the third stage of labor should be managed if there are no uterotonic
drugs available.
In the context of prevention of PPH, if uterotonic drugs are not available, the third stage
should be managed physiologically.

Core Topic 3b: Managing uterotonic drugs
1. Case study: The pharmacy manager is preparing her monthly order request and would
like to calculate how many ampoules of oxytocin 10 IU to order. When she carried out
an inventory, she counted 50 ampoules of oxytocin 10 UI, of which 4 ampoules were
expired. The average monthly consumption is 30 ampoules of oxytocin (10 UI). How
many ampoules should the pharmacy manager order? Please show your calculations.
[Quantity to order = (Average monthly consumption × Lead time + 1 month
consumption for unforeseen events) – (Stock in balance over RI)]
o Delay (lead) time : 1 month
o Stock in balance : (50 ampoules – 4 expired ampoules) = 46 ampoules in
balance
o Average monthly consumption : 30 ampoules
o RI : (30 ampoules x 1 month) = 30 ampoules
o Stock in balance over RI = 46-30 = 16 ampoules over the RI
o Quantity to order : [(30 x 1) + (30)] – (16) = 44 ampoules
2. Calculate the request indicators (RI) for each of the health care facilities below:
a. Average monthly consumption = 20 ampoules of oxytocin (10 UI)
Delay (lead) time: 3 months
RI = 20 x 3 = 60 ampoules
b. Average monthly consumption = 45 ampoules of oxytocin (10 UI)
Delay (lead) time: 1 month
c. Average monthly consumption = 12 ampoules of oxytocin (10 UI)
Delay (lead) time: 2 months
3. Calculate the quantity of oxytocin 10 IU ampoules to be ordered for the following health
care facilities:
a. Average monthly consumption = 20 ampoules of oxytocin (10 UI); delay (lead)
time : 6 months; stock in balance = 12 ampoules of oxytocin (5 UI)
Stock in balance over/under RI = 120-6 = 114 ampoules under the RI
Quantity to order = (20 x 6) + 20 + (114) = 254 ampoules
b. Average monthly consumption = 45 ampoules of oxytocin (10 UI); delay (lead)
time : 1 month; stock in balance = 62 ampoules of oxytocin (10 UI)
Stock in balance over/under RI = 62-45 = 17 ampoules over the RI
Quantity to order = (45 x 1) + 45 - (17) = 73 ampoules
c. Average monthly consumption = 12 ampoules of oxytocin (10 UI); delay (lead)
time : 2 months; stock in balance = 18 ampoules of oxytocin (10 UI)
Stock in balance over/under RI = 24-18 = 6 ampoules under the RI
Quantity to order = (12 x 2) + 12 + (6) = 42 ampoules

4. Exercise: Find the errors in the bin (stock) card below.
a. What errors did the pharmacy manager make when calculating what quantity to
order?
• The same quantity was ordered regardless of consumption or stock in balance.
Delay (lead) time = 1 month; RI (Minimum stock level) = 30.
• Quantity ordered on 1/7/07 should have been: (30 x1) + 30 + (30-0) =90
ampoules
• Inventory was not done before the order on 31/7, so it is difficult to know how
many ampoules should have been ordered.
• Quantity ordered on 1/9/07 should have been: (30 x1) + 30 + (30-45) =45
ampoules
• Expired ampoules were not removed until inventory.
• 4 ampoules were unaccounted for.
b. What are the advantages to correctly documenting movement of uterotonic drugs?

• To avoid shortages (out of stock) and ensure credible health care service,
• To prevent excess stock and avoid waste (loss or mismanagement of financial
resources).

1. Review the information comparing the three most commonly used uterotonic drugs:
oxytocin, ergometrine, and misoprostol. Rate these drugs on a scale of 1 to 3 for their
stability (1 being most stable, 3 being least stable) when exposed to heat and light.
Factor affecting drug stability Oxytocin Misoprostol Ergometrine
Stability when exposed to heat 2 1 3
Stability when exposed to light 2 1 3

Most stable=1; Least stable=3
2. Carefully read each of the case studies below and provide instructions for (1) storing
uterotonic drugs in the delivery room and (2) storing uterotonic drugs in the pharmacy
depot.
a. Case study 1: Your pharmacy manager regularly orders oxytocin and ergometrine.
The health centre has reasonably reliable electricity, and the electric refrigerator in the
pharmacy is in good condition. The maternity ward delivery room does not have a
refrigerator. The regional and national pharmacies have refrigerators, and there is an
effective cold chain system for transporting vaccines. The average temperature at the
health centre during the hot season is 45°C in the shade.
Pharmacy: Delivery room:
• Make sure that quantification of • Periodically remove ample amount
drugs is being calculated based on of injectable uterotonic drugs
recommendations needed for expected client load from
• Check manufacturer’s label for refrigerator
storage recommendations • Avoid storage of injectable
• Follow the rules of first expired – uterotonic drugs in open kidney
first out / first in – first out to dishes, trays, or coat pockets
reduce wastage of uterotonic drugs • Store ergometrine and Syntometrine
• If possible, keep injectable vials outside the refrigerator in
uterotonic drugs refrigerated at 2– closed boxes and protected from the
8°C light for up to one month at 30°C
• Make sure that there is a system in • Store oxytocin outside the
place to monitor the temperature of refrigerator at a maximum of 30°C
the refrigerator / cold box (warm, ambient climate) for up to
• Protect ergometrine and three months
Syntometrine from freezing and • Store misoprostol at room
light. temperature away from excess heat
• Store misoprostol at room and moisture
temperature and away from excess
heat and moisture

b. Case study 2: The pharmacy manager prefers to order medication once per quarter
and will only order ergometrine for the health centre. The health centre has only one gas
refrigerator located in the consultation room for children under six years of age. This
refrigerator is not in very good condition, and there are frequent gas stock-outs. The
regional and national pharmacies have refrigerators, and there is an effective cold chain
system for transporting vaccines. The average temperature at the health centre during
the hot season is 23°C in the shade.
• Explain the reasons why oxytocin is the preferred uterotonic for prevention and
treatment of PPH and encourage your pharmacy manager to begin ordering
oxytocin in addition to ergometrine
• Discuss misoprostol as an alternate uterotonic drug
• Store ergometrine and oxytocin in the gas refrigerator
• See answer for Case study 1
c. Case study 3: When you picked up an order of uterotonic drugs at the regional
pharmacy, you discovered the drugs were not stored in the refrigerator. There is an
effective cold chain system for transporting vaccine. Your health centre does not have
electricity but there is one UNICEF gas refrigerator for vaccinations. The EPI does not
allow anything but vaccinations to be stored in the refrigerator. The average
temperature at the health centre during the hot season is 31°C in the shade.
• The effectiveness of the uterotonic drugs you are picking up is questionable. Talk
with people responsible for the regional pharmacy about the effects of heat on
oxytocin and ergometrine, and the effects of light on ergometrine.
• Talk with the person responsible for storing vaccinations and get her/his approval
for storing uterotonic drugs in the refrigerator by explaining recommendations for
storage of uterotonic drugs
d. Case study 4: You are unsure if the national or regional pharmacies store uterotonic
drugs in a refrigerator. You know that uterotonic drugs are transported in cold boxes
when delivered to the health centre. The maternity ward uses an electric refrigerator
that is in good condition, and only medications and products used in the maternity ward
are kept inside. Only the Matron has a key to open the refrigerator. The average
temperature at the health centre during the hot season is 42°C in the shade.
• The effectiveness of the uterotonic drugs you are picking up is questionable. Talk
with people responsible for the national and regional pharmacy to see if
uterotonic drugs are stored in a refrigerator at their pharmacies. If uterotonic
drugs are not stored in refrigerators at the regional and national level, explain
the effects of heat on oxytocin and ergometrine, and the effects of light on
ergometrine.
• Talk with the Matron to find a solution for making sure that uterotonic drugs are
available when she is not on duty

3. Read the following short case studies carefully and decide if the uterotonic drugs
described are still active or may have lost some of their effectiveness. Justify your
responses.
a. Case study 1: The health centre does not have a refrigerator. The average
temperature is 40°C. The health centre received its last consignment of oxytocin and
ergometrine four months ago. Because the health centre has many births, both the
oxytocin and ergometrine are stored in a delivery room desk drawer, out of the box.
• The effectiveness of both oxytocin and ergometrine is questionable. Oxytocin can
be temporarily stored outside the refrigerator at a maximum of 30°C for no more
than three months; ergometrine needs to be stored at 2 – 8°C and should be
kept in the dark.
b. Case study 2: The national pharmacy stores oxytocin in a refrigerator between 2°C
and 8°C, and the health centre has a reliable refrigerator in good working condition.
Unfortunately, there is no cold chain for uterotonic drugs and it takes three days for an
order of ergometrine and oxytocin to be transported from the national pharmacy to the
health centre. At this time of year the average temperature is 43°C in the shade.
• Both oxytocin and ergometrine should still be effective. Oxytocin can be
transported unrefrigerated if the transport takes no more than one month at
30°C; ergometrine can be transported unrefrigerated in the dark is possible if
the transport takes no more than one month at 30°C.
c. Case study 3: On average, there are 25 births per month at the health centre, and
the team keeps oxytocin in the delivery room. In consultation with the head midwife,
you remove 30 ampoules at a time from the refrigerator and store them in the delivery
room in their package, in the shade, and away from sunlight. You develop a system to
mark each package with the date the oxytocin was removed from the refrigerator and
discard the drug if it has been out of the refrigerator for more than two weeks. The
average daily temperature is 38°C.
• Oxytocin should still be effective. Oxytocin can be temporarily stored outside the
refrigerator at a maximum of 30°C for no more than three months.

True or False
False 1. Oxytocin is less stable than ergometrine when exposed to light.
False 2. Oxytocin is less stable than ergometrine when exposed to heat.
False 3. Ampoules of ergometrine and oxytocin cannot be stored outside the
refrigerator in the delivery room.

4. Study the time temperature indicators below, then answer the following questions:
A B
C D
a. Which ampoule should be used first? C

b. Which ampoule(s) can still be used? B, C
c. Which ampoule(s) should be discarded? A, D

Core Topic 4: AMTSL

True or False
True 1. Delaying cord clamping by two to three minutes is beneficial for the baby.
True 2. Regardless of how the third stage of labor is managed, basic care for the woman
and baby during labor and the postpartum period remains the same.
False 3. If the third stage of labor is managed actively, the cord will need to be clamped
immediately after birth to facilitate CCT.
True 4. Essential care for the woman and newborn includes following national guidelines
for maternal interventions to prevent/reduce the risk of MTCT of HIV/AIDS.
True 5. Whether the third stage is managed actively or physiologically, place the newborn
in skin-to-skin contact with the woman immediately after birth, then cover them
both with a dry, warm cloth or blanket.

Short answer
In the space provided, write a brief answer to each question.
1. If your health care facility does not have oxytocin, what uterotonic drug should you use
in its place?
• Ergometrine, Syntometrine, or misoprostol.
2. Which will happen first: drying the baby or administering a uterotonic drug?
• Drying the baby.
3. Explain why you should load a syringe with oxytocin at the beginning of the second
stage rather than during the third stage of labor.
• Events happen quickly, and you have only one minute after childbirth to administer
the uterotonic drug for AMTSL. During this minute, you must dry and assess the
baby, cover the baby and mother, and rule out the presence of another baby before
giving the uterotonic drug. Preparing the syringe when the second stage begins
means that the uterotonic drug will be ready to administer as soon as you have ruled
out the presence of another baby.
4. Explain the purpose of AMTSL.
• Stimulate uterine contractions that will speed separation of the placenta from the
uterine wall.
• Speed the delivery of the placenta after it has separated from the uterine wall by
using CCT.
• Prevent uterine atony by stimulating uterine contractions and performing uterine
massage.

5. List the three main steps of AMTSL.
• Administration of a uterotonic drug within one minute after birth of the baby.
• CCT with countertraction to the uterus.
• Uterine massage after delivery of the placenta.
6. How do you help prevent the thin membranes from tearing off as the placenta delivers
spontaneously?
• As the placenta delivers, hold it in both hands and gently turn it until the membranes
are twisted.
• Slowly pull to complete the delivery. Move membranes up and down until they
deliver.
7. What must the provider rule out before giving oxytocin for AMTSL?
• An additional baby or babies.
8. To safely perform CCT for delivery of the placenta, the provider holds the clamped cord
with one hand. With the other hand placed on the woman’s abdomen above the pubic
bone, the provider pushes the uterus upwards toward the woman’s head. Why does the
provider push the uterus upward?
• To stabilize the uterus and prevent uterine inversion.
9. Ms. B had a spontaneous vaginal birth and delivery of the placenta with AMTSL. When
estimating Ms. B’s blood loss, what is the expected normal blood loss?
• Less than 500 mL.
10. What should you do if the placenta does not descend during 30 to 40 seconds of CCT?
• Release tension on the cord while still holding the cord and then release pressure on
the uterus. Wait for the next contraction.
• Repeat CCT with countertraction on the uterus with the next contraction.
Learning activity 4.3.

Short answer
Write a short answer in the space provided.
1. Describe 3 areas of the placenta you will examine and why.
• Fetal side of the placenta to ensure it is complete.
• Maternal sides of the placenta to ensure they are complete.
• Membranes to ensure they are complete.
2. Describe two things to verify before assisting the woman to initiate breastfeeding.
• The mother’s choice for infant feeding.
• Readiness of the mother and baby to breastfeed.
3. Describe why examination of the placenta and genitals is important for preventing PPH.
• The uterus cannot adequately contract if retained placental fragments or membranes
are left inside. Retained placenta or placental fragments are the third leading cause
of PPH.
• Unrepaired genital tears can result in loss of considerable amounts of maternal
blood. Genital tears are the second leading cause of PPH.

4. Describe three things to explain to the woman about caring for herself in the immediate
postpartum.
• Instruct the woman how the uterus should feel and how she can massage it herself.
• Encourage the woman to eat and drink.
• Encourage the woman to pass urine.
• Inform the woman about danger signs and when she should call for help.

(Estimated time to complete this activity: 15 minutes)
True or false
1. False Once the 3rd stage of labor is completed, the mother does not need regular
assessment as there is no longer danger of complications.
2. False The only time a woman and her newborn should both receive a comprehensive
examination is just before being discharged from the facility.
3. False If a newborn baby is breathing 42 times in a minute, this is abnormal and
requires immediate assessment by a pediatrician.
4. True The uterus should be hard and round when you examine the woman 1 hour after
birth.
5. True At the first hour after birth, the newborn should be assessed for any birth injury.
6. True Palmar or conjunctival pallor in the woman associated with 30 respirations per
minute or more is considered a danger sign.
7. True It is important to keep the mother and her baby together in the first hour in the
delivery room.

Short answer
1. Describe how management of the third stage of labor may be different if the birth
attendant is alone and the newborn needs to be resuscitated.
• Administer a uterotonic drug within one minute after the baby is born (oxytocin 10
IU IM or misoprostol 600 mcg orally) and a second twin has been ruled out.
Note: Do not use ergometrine or Syntometrine in the case where CCT may not be
possible. Ergometrine causes tonic clonic contractions that may entrap the
placenta.
• Deliver the placenta either by maternal effort or, if possible, CCT with simultaneous
countertraction to the uterus.
• Perform uterine massage immediately after delivery of the placenta.
2. List the steps for managing the third stage of labor if the birth attendant is alone and
does not have time to administer a uterotonic drug.
• Manage the third stage physiologically.
• Perform uterine massage immediately after delivery of the placenta.

3. Explain why CCT is not recommended if the provider did not administer a uterotonic
drug.
• CCT is applied to speed delivery of the placenta after it has separated from the
uterine wall. If a uterotonic drug has not been administered to stimulate contractions
and speed separation from the uterine wall, CCT may result in inversion of the uterus
because it is being applied before the placenta has separated from the uterine wall.

True or False
In the space provided, write “T” for true or “F” for false for each statement. Explain your
answer in the space provided below the statement.
1. CCT should not be applied if the woman is infected with HIV because this may increase
the risk of MTCT of HIV.
False. CCT speeds delivery of the placenta after it has separated from the uterine wall
and ensures that the uterus is empty so that it can contract and stop bleeding from the
placental site. PMTCT interventions include preventing hemorrhage during the third
stage of labor.
2. Management of the third stage of labor should be the same whether or not the woman’s
HIV status is positive.
True. PMTCT interventions include preventing hemorrhage during the third stage of
labor; therefore AMTSL can be seen as an intervention to reduce the risk of MTCT of
HIV.
3. PMTCT interventions may interfere with AMTSL steps.
False. PMTCT interventions can be integrated without a problem into active management
of the third stage of labor.

True or False
False 1. If oxytocin is supplied in ampoules of 5 IU, only 1 ampoule is necessary for AMTSL
when giving oxytocin intramuscularly (IM).
True 2. Routine manual exploration of the uterus after AMTSL is not recommended and
may be harmful.
True 4. If there is an undiagnosed twin and the provider administers oxytocin, there is a
theoretical risk that the twin could be trapped in the uterus.
False 5. When uterotonic drugs are not available, CCT alone can reduce the incidence of
PPH or severe PPH.
False 6. Nipple stimulation can replace use of uterotonic drugs to prevent PPH.

Additional topic 1: Prevention of infections

For each practice or situation described below, select whether it is an acceptable or
unacceptable practice. Explain your answer.
• A doctor washes his hands by dipping them in a basin of water before examining a
patient.
Unacceptable: Hands can be contaminated by dipping them in a basin of water. Standing
water can easily become contaminated even if antiseptic is added.
• If there is no running water at a clinic, one staff member pours water over the other's
hands for hand washing.
Acceptable: If there is no running water, this practice is an acceptable substitute, as
long as the water being poured is clean.
• A large bar of soap is kept in a closed saucer for use by all personnel in the examination
room.
Unacceptable: Small pieces of soap kept in a dish that allows drainage are best. A large
bar of soap in a dish with no drainage can become contaminated easily.
• Staff members wash their hands for approximately five seconds.
Unacceptable: Staff must wash their hands for 10 to 15 seconds.
• A staff member arrives at the clinic to find many people waiting for her, so she
immediately begins seeing clients without washing her hands.
Unacceptable: Staff should wash their hands when they arrive and before they leave a
health facility.

1. A midwife puts her gloves in the labor room sink after using them.
Unacceptable: Gloves should be decontaminated immediately after use and then
discarded or cleaned and high-level disinfected or sterilized.
2. A doctor rubs up the fundus after delivery of the placenta without using gloves.
Unacceptable: The woman’s abdomen can be contaminated by body fluids and blood
during countertraction and skin-to-skin contact with the newborn and exam gloves
should be worn to protect the provider.
Write True or False for each statement, and explain your answer.
3. A provider does not need to wear gloves when handling a baby after delivery if the baby
has been well-dried.
False. Gloves should be worn to protect the baby and provider.
4. Gloves provide a barrier against possible infectious microorganisms that can be found in
blood, other body fluids, and waste.
True

5. The risk of having a needlestick injury is much less if sterile gloves are used.
False. Gloves cannot protect any needlestick injuries.
6. Even when gloves are sterile, they should not be used if there are holes in them.
True. Any time a glove has a hole in it, it is can no longer protect the provider or the
client from infection.
7. The most effective way to prevent infection in health care facilities is to wear gloves.
False. The most effective way to prevent infection in health care facilities is careful and
adequate handwashing.

1. To reduce the risk of a needle stick, recap a needle by holding the syringe in one hand
and holding the needle in the other hand.
False: You should avoid recapping needles. If you need to recap, do so using the one-
hand method.
2. Housekeeping staff are rarely at risk of injury or infections caused by sharps—such as
hypodermic needles or scalpel blades—because they are not directly involved in client-
care activities.
False: Housekeeping staff are often at risk of injury or infection by sharps.
3. The provider drops instruments into a bucket with decontamination solution to avoid
contact with the solution.
Unacceptable: Place items in the decontamination bucket without splashing the solution.
4. The provider artificially ruptures membranes during a contraction to prevent splashes.
Unacceptable: Avoid rupturing membranes during a contraction to prevent splashes.
5. When a nurse accidentally got blood on her hands, she washed her hands vigorously
with a 0.5 percent chlorine solution.
Unacceptable: If blood or body fluids get in your mouth or on your skin, wash with
plenty of water and soap as soon as it is possible and safe for the woman and baby.
Chlorine is corrosive and can cause cracks in the provider’s skin which will increase the
risk of infection.

1. One of the goals of appropriate waste disposal at the health care facility is to prevent
transmission of infections to the local community.
True. One important purpose of waste disposal is preventing the spread of infection to
the local community.
2. All waste from a hospital is infected, even waste from the secretary’s waste bin.
False. There is no risk from non-contaminated waste such as office paper, which can be
disposed of according to local guidelines.

3. Liquid medical waste should never be disposed down a sink, drain, toilet, or latrine.
False. Liquid medical waste can be disposed down a sink, drain, toilet, or latrine. If this
is not possible, bury it along with solid medical waste.
4. Solid medical waste should be burned or buried.
True.
5. Housekeeping staff do not need to wear gloves when handling non-contaminated waste
such as office paper.
False. While office paper is not contaminated and poses no risk to housekeeper,
housekeepers should wear utility gloves at all times to protect themselves against
accidental exposure to potential contaminants.

1. Decontamination kills all microorganisms on soiled instruments and other items.
False: Decontamination kills viruses such as HIV and many—but not all—other
microorganisms.
2. Cleaning instruments before sterilizing them is not necessary if they were soaked in a
0.5 percent chlorine solution for 10 minutes.
False: Although decontamination makes items safer to handle, cleaning is still necessary
to remove organic material, dirt, and other matter that can interfere with further
processing.
3. Sterilizing may not be effective if blood and other organic material are not cleaned from
instruments before sterilizing.
True: It is important to clean items before sterilization; microorganisms trapped in blood
and other matter can survive the sterilization process.
4. High-level disinfection (HLD) kills all microorganisms.
False: HLD does not reliably kill all bacterial endospores.
5. When preparing a chlorine solution for decontamination, it is important to know the
amount of active chlorine in the product used.
True: It is important to know the amount of active chlorine in order to make a solution
of the correct strength for decontamination.
Preparation of a decontamination solution
6. Calculate the appropriate dilution to prepare a 0.5 percent chlorine solution using each
of the chlorine preparations below:
Chlorine
Parts water Parts chlorine
preparation
2.4% 4 parts water 1 part bleach
5% 9 parts water 1 part bleach
15% 29 parts water 1 part bleach

7. Calculate the appropriate dilution to prepare a 0.5 percent chlorine solution using each
of the chlorine preparations below:
Preparation % Active chlorine Gms/Liter

Calcium
70% 7.1 grams per liter
hypochlorite
Calcium
35% 14.2 grams per liter
hypochlorite

Additional topic 2: Birth preparedness and complication

readiness
Read the following case study carefully and answer the questions that follow. Justify your
responses.
Case study: Ms. K’s (age 32) first antenatal visit is at 32 weeks. Her village is 15
km away, and she arrived in the back of an open truck—the only transportation
available. Her traditional birth attendant suggested she come to the health center for
antenatal care.
She has given birth 8 times, and only two of her children are alive today. Her last
baby was stillborn, the result of a long, difficult labor; she says the baby was moving
well until the end of labor. After 24 hours of labor, the traditional birth attendant
decided to send her to the health center. Because her husband was away at the time
and no one wanted to take responsibility for her, they waited another day for her
husband to return home. Although the husband decided to send her to the health
center, it took several hours for him to gather enough money for the trip. The doctor
delivered the baby with a vacuum, and after the birth, Ms. K bled significantly.
Questions
4. What about Ms. K’s case indicates why it is important she have a birth plan?
Geographic and transportation issues:
• Her village is 15 km away.
• She travels in an open truck because is the only form of transport available.
Financial and decision-making issues:
• After labor had gone on for 24 hours, the traditional birth attendant decided to
send her to the health center, but her husband had been away and no one wanted
to take the responsibility of sending her, so they had to wait another day until the
husband came home.
• Even though the husband decided to send her to the health center, it took him
several hours to get enough money to send her.
Previous obstetric complications:
• She has given birth 11 times, only 2 of her children are alive; her last baby was
stillborn, and apparently died during a long, hard labor (she says the baby was
moving well until the end of labor).
• The doctor delivered the last baby with a vacuum.
• After the birth, she says she bled a lot.
5. Where do you recommend Ms. K give birth?
• Ms. K should give birth with a skilled provider, most likely in a health center where
vacuum birth/cesarean operation are possible, or she should give birth at the
hospital.
6. List the important topics to address in the BPP.
Developing a BPP
• Make plans for the birth.
- Place of birth.
- Chosen skilled provider.

- How to contact the provider.
- How to get to the place of birth.
- Who will be the birth companion?
- Who will take care of the family while the woman is absent?
• Prepare the necessary items for birth.
• Establish a financing plan/scheme.
- How much money will be required and how to get access to this money

Read the story of Ms. Kebede and identify the delays which led to her death.
Ms. Kebede is a grand multipara who lives in a village where there are no health services.
She did not have a prenatal consultation and when labor began, she called on members of
her family. After a while, the family members realized that her labor was not progressing
normally.
The family called on the Traditional Birth Attendant who said that the labor was not normal.
She was then referred to a higher level of service, but first means of transporting her had to
be found.
Ms. Kebede arrived at the health center at 12:10 p.m. on March 23.
When she arrived, the service providers noted that the head of the baby was at the vulva
and that Ms. Kebede was no longer having contractions.
Ms. Kebede was kept at the health center for 4 hours before a decision was made at 4:50
p.m. on March 23 to evacuate her to the district hospital (DH) (because she “refused to
make the effort to push”).
Nothing was done to provide first aid (not even an IV, etc.).
Evacuation was delayed because the family had to seek some means of transportation.
Ms. Kebede arrived at the DH at 8:30 a.m. on March 24.
The general surgeon does not operate on uterine ruptures; furthermore, another woman
was already waiting for a cesarean because she had a scarred uterus. Therefore, Ms.
Kebede had to be evacuated to the regional hospital.
The decision to evacuate her was made at 8:52 a.m., means of transportation were found
at 9:00 a.m., and the woman left the DH at 10:30 a.m.
Ms. Kebede arrived at the regional hospital at 12:30 p.m. The staff tried to stabilize her and
took her to the operating room at 1:00 p.m.
Ms. Kebede died in the operating room at 1:15 p.m. as she was receiving general
anesthesia.

1. Identify the delays that led to Ms. Kebede’s death.
Ms. Kebede is a grand multipara who lives in a village where

Delay in there are no health services. She did not have a prenatal
recognizing consultation and when labor began, she called on members of
the problem her family. After a while, the family members realized that
her labor was not progressing normally.
The family called on the traditional birth attendant who said

that the labor was not normal. It was then decided to refer
Delay in her to a higher level of service but first, means of
deciding to transporting her had to be found. Ms. Kebede arrived at the
health center at 12:10 p.m. on March 23.When she arrived,
seek care
the service providers noted that the head of the baby was at
the vulva and that Ms. Kebede was no longer having
contractions.
Ms. Kebede was kept at the health center for 4 hours before a
Poor quality decision was made at 4:50 p.m. on March 23, to evacuate her
of care to the DH (because she “refused to make the effort to push”).
Nothing was done to provide first aid (not even an IV, etc.).
Delay in Evacuation was delayed because the family had to seek some
arriving at means of transportation. Ms. Kebede arrived at the DH at
the DH 8:30 a.m. on March 24.
The general surgeon does not operate on uterine ruptures;

furthermore, another woman was already waiting for a
cesarean because she had a scarred uterus. Therefore, Ms.
Delay in Kebede had to be evacuated to the regional hospital.
receiving The decision to evacuate her was made at 8:52 a.m., means
care of transportation were found at 9:00 a.m., the woman left the
DH at 10:30 a.m.
Ms. Kebede arrived at Regional Hospital at 12:30 p.m. The
staff tried to stabilize her and took her to the operating room
at 1:00 p.m.
Maternal Ms. Kebede died in the operating room at 1:15 p.m. as she
death was receiving general anesthesia.

2. List the delays that could have been prevented if Ms Kebede had received quality
obstetric care.
• Adequate preparation during antenatal care and development of a BPP would have
prevented the following delays:
o Delay in receiving care
Ms K would have planned to give birth with a skilled birth attendant.
Ms K would have planned for transport and funds.
Ms K did not receive quality care until she reached the national
hospital, when it was too late.
o Delay in recognizing the problem—Ms K and her family would have recognized
the need to seek care earlier if they had been taught the danger signs.

Short answer
1. List the elements of a CRP you will develop with a woman who gave birth in your facility
and is now ready to be discharged.
Developing a CRP
• Know danger signs.
• Establish a savings plan/scheme.
• Make a plan for decision-making in the case of an emergency that occurs in the
absence of the chief decision-maker.
• Arrange a system of transport in case of emergency.
• Arrange for a blood donor.
2. Explain why you should assist a woman to develop a CRP before she goes back home
after giving birth.
• Most maternal and newborn deaths occur within the first week postpartum.
3. List all the people who will need to be involved when you are developing a CRP.
• The woman, her partner/husband, and family members who will help take care of
the woman and her newborn.
4. Mme. Ballo is 20 years old, and she just gave birth to a healthy baby boy at the health
center. Her baby had to be resuscitated, but is doing well now and is breastfeeding
without any problems. Mme. Ballo had a second-degree perineal tear that was repaired
without incident. She is happy, healthy, and is very eager to go home. What danger
signs will you teach Mme. Ballo and her family?
Maternal danger signs include:

• Vaginal bleeding (any vaginal bleeding during pregnancy; heavy vaginal bleeding or
a sudden increase in vaginal bleeding during the postpartum period).
• Breathing difficulties.
• Fever.
• Severe abdominal pain.
• Severe headache/blurred vision.
• Convulsions or loss of consciousness.
• Foul-smelling discharge from vagina, tears, and incisions.

• Calf pain with or without swelling.

• Night blindness.
• Verbalization or behavior indicating she may hurt the baby or herself.
• Hallucinations.
Newborn danger signs include:

• Breathing problems.
• Feeding difficulties or not sucking.
• Feels cold or has fever.
• Redness, swelling, or pus from eyes or around the cord or umbilicus.
• Convulsions or fits.
• Jaundice (yellow skin).

Additional topic 3: Managing complications during the third

stage of labor
Read each of the following case studies and determine if the woman is in shock. Write your
answer in the right-hand column.
Assessing shock
Shock?
Case studies
Yes/No
1. Ms. A gave birth at home about 4 hours ago. She has come to
the health center because of heavy vaginal bleeding. Vital
signs: pulse: 96 beats/minute; blood pressure: 110/70;
No
respirations: 21/minute; temperature: 37°C; conjunctivae are
pale; extremities are warm; she is conscious; she recently
passed a large amount of urine.
2. You assisted Ms. B during childbirth. Labor was prolonged and

she received an IV drip of oxytocin to augment uterine
contractions. Ms. B gave birth soon after the IV was started
and you performed AMTSL. Thirty minutes after delivery of
the placenta, Ms. B is still bleeding heavily. Vital signs: Yes
pulse: 112 beats/minute; blood pressure: 80/40; respirations:
36/minute; temperature: 36°C; conjunctivae are pale;
extremities are cold; Ms. B is very anxious; you don’t recall
the last time she urinated.
3. Mme. C is 38 weeks pregnant. She has come to the health

center because of vaginal bleeding and severe abdominal
pain. She thinks she is in labor. Vital signs: pulse: 82
beats/minute; blood pressure: 130/90; respirations: No
24/minute; temperature: 37.5°C; fetal heart tones: absent;
conjunctivae are pale; extremities are cold; Mme. C is very
anxious; she can’t remember the last time she urinated.
4. Mme. D gave birth in the health center last night. During

rounds, you monitor her progress. Vital signs: pulse: 132
beats/minute; blood pressure: 70/-; respirations: 32/minute;
Yes
temperature: 36°C; conjunctivae are pale; Mme. D appears
confused and has cold, clammy skin; she last urinated before
giving birth.

1. Ms. F just gave birth to a healthy baby. The placenta has delivered and it is followed by
a large amount of bright red blood. You estimate that over 500 mL of blood have been
passed. You know that bleeding is an emergency that causes many deaths. Think of how
you will take care of Ms. F. Without looking back at the text, write down the steps you
will take to assess her condition.
Shout for help!

Make a rapid evaluation of the general condition of the

woman, including vital signs (pulse, blood pressure,
respiration, temperature).
If shock is suspected, immediately begin treatment. Keep

shock in mind even if there are no signs present.
Massage the uterus to expel blood and blood clots.
Start an IV infusion. Collect blood just before infusion

of fluids. Infuse IV fluids.
Help the woman empty her bladder.
Check to see if the placenta is expelled, and examine the

placenta for completeness. Examine the vagina, perineum,
and cervix for tears.
Determine the cause of bleeding and begin treatment.


1. Read each of the following case studies and write the probable diagnosis in the right-
hand column.
Probable
Case studies
diagnosis
• Ms. A gave birth 35 minutes ago. Her baby needed

resuscitation, and because you were alone, you did not
Retained placenta
use AMTSL. The baby is fine, but Ms. A is now bleeding
heavily and the placenta has not been expelled.
• Ms. B gave birth 20 minutes ago. You actively managed

the third stage of labor and the placenta was complete. Genital
Ms. B is bleeding heavily now, and her uterus is well- lacerations
contracted.
• Ms. C gave birth 40 minutes ago. You actively managed

the third stage and think the placenta was complete. Her
Cervical tear
uterus is well-contracted and she has no vaginal or
perineal tears.
• Ms. D gave birth 30 minutes ago. You actively managed

Retained
the third stage, but she is now bleeding heavily and her
placental
uterus is soft. She has no vaginal or perineal lacerations.
fragments and
When you recheck the placenta, you see that one or more
uterine atony
lobes is missing.
• Ms. E just gave birth, and you have just completed CCT to
deliver the placenta and want to massage the uterus.
Inverted uterus
When you try to massage the uterus, you do not feel the
uterine fundus.
• Ms. F gave birth 15 minutes ago. You actively managed

the third stage, the placenta was complete, and she has
Uterine atony
no vaginal or perineal lacerations. You find Ms. F in a pool
of blood and her uterus is soft.

1. Circle the answer with the correct indication for using internal bimanual uterine
compression to control PPH. .
a. If vaginal bleeding continues after massaging the uterus and administering
uterotonic drugs.
b. After attempting aortic compression without success.
c. When a vaginal tear is the identified cause of bleeding.
d. When the placenta has not been delivered 30 minutes or more after birth of the baby.
2. Mme. Coulibaly, para 4, is 30 years old. She gave birth at the health center to a healthy
term baby, weighing 4.2 kg. You gave Mme. Coulibaly oxytocin 10 IU IM and applied
active management of the third stage of labor. The placenta was delivered without
complications. Mme. Coulibaly calls you 30 minutes after delivery of the placenta
because she says her vaginal bleeding has suddenly increased.
a. What will you do in your initial assessment of Mme. Coulibaly, and why?
• Mme. C. should be told what is going to be done and listened to carefully. In
addition, her questions should be answered in a calm and reassuring manner.
• At the same time, a rapid assessment should be done to check for signs of shock
(rapid, weak pulse, systolic blood pressure less than 90 mm Hg, pallor and
sweatiness, rapid breathing, confusion).
• The placenta should be checked thoroughly for completeness.
b. Which aspects of Mme. Coulibaly’s physical examination will help make an immediate
diagnosis or identify her problems/needs, and why?
• Mme. C’s uterus should be checked immediately to see whether it is contracted.
If the uterus is contracted and firm, the most likely cause of bleeding is genital
trauma. If the uterus is not contracted and the placenta is complete, the most
likely cause of bleeding is an atonic uterus. The most important causes of
bleeding can be suspected by palpating the uterus.
• Her perineum, vagina, and cervix should be examined carefully for tears.
3. You have completed your assessment of Mme. Coulibaly, and your main findings include
the following:
Mme. Coulibaly’s vital signs: pulse: 88 beats/minute; blood pressure: 110/80
mm Hg; respiration 18 breaths/minute; temperature: 37ºC. Her uterus is soft.
The placenta is complete, and she doesn’t have perineal trauma.
c. Based on these findings, what is Mme. Coulibaly’s diagnosis, and why?

• Mme. C’s symptoms and signs (e.g., immediate postpartum hemorrhage,
placenta complete, and uterus well-contracted) are consistent with genital
trauma.
d. How will you manage her vaginal bleeding?
• An IV should be started using a large-bore needle to replace fluid loss, using
Ringer’s lactate or normal saline.
• A careful speculum examination of the vagina and cervix should be conducted
without delay, as tears of either the cervix and/or the vagina are the most likely
cause of Mme. C’s bleeding.
• Any tears should be repaired immediately.

• Mme. C’s vital signs and fluid intake and output should be monitored.
• Her uterus should also be checked to make sure that it remains firm and well-
contracted.
• Blood should be drawn for hemoglobin and cross-matching, and blood for
transfusion should be made available as soon as possible, in the event that it is
needed.
• The steps taken to manage the complication should be explained to Mme. C. She
should be encouraged to express her concerns, listened to carefully, and provided
emotional support and reassurance.

Multiple choice
Read each question below and circle the letter corresponding to the best answer.1
1. Tears of the birth canal:

a. Are the second most common cause of PPH.
b. May be present at the same time as uterine atony.
c. Should be repaired as quickly as possible to minimize blood loss.
d. All of the responses are correct.
2. Mme. Bâ gave birth 15 minutes ago. She is bleeding heavily. What actions will you take?
a. Call for help, perform a manual revision of the uterus, and catheterize the bladder.
b. Call for help, make a rapid evaluation of the general condition of the
woman, massage the uterus, and administer oxytocin 10 IU IM.
c. Call for help, catheterize the bladder, do internal bimanual compression of the uterus
3. If a woman is bleeding after giving birth, her uterus is well-contracted, the placenta and
membranes are complete, and you find no perineal or vaginal lacerations, you should
rule out:
a. Coagulopathy.
b. Retained placenta.
c. Cervical laceration.
d. Uterine atony.
4. If, while you are repairing a perineal laceration, the woman begins bleeding heavily and
you note her uterus is soft, what will you do?
a. Perform a manual revision of the uterus and finish repairing the perineal laceration
after her bleeding is under control.
b. Finish repairing the perineal laceration and then do a bedside clotting test.
c. Immediately do internal bimanual compression of the uterus to manage uterine
atony.
d. Massage the uterus.
1 Adapted from Managing Complications in Pregnancy and Childbirth. Learning Resource Package:
6
Guide for Teachers; JHPIEGO/Maternal & Neonatal Health.

5. If you have completed repair of genital lacerations, the uterus is well-contracted, the
placenta and membranes are complete, but the woman continues bleeding, you should:
a. Perform a manual revision of the uterus.
b. Administer a uterotonic.
c. Do a bedside clotting test.
d. Immediately do internal bimanual compression of the uterus.

1. Ms. B gave birth 30 minutes ago, but the placenta has not yet been delivered. She is
bleeding heavily. Before attempting manual removal of the placenta, what actions
should you take to encourage placental separation and expulsion?
a. Bimanual compression of the uterus
b. Catheterize the bladder, give oxytocin IM, and apply gentle cord traction.
c. Fundal pressure.
d. Aortic compression.
2. Ms. B had PPH and you had to manually remove the placenta. Before she goes home
from the facility, you will tell her to come back to the health care facility if there are
any signs of danger. List 4 indications of problems that you will explain to her.
Maternal danger signs that may indicate infection include:

• Vaginal bleeding (any vaginal bleeding during pregnancy; heavy vaginal bleeding
or a sudden increase in vaginal bleeding during the postpartum period).
• Fever.
• Severe abdominal pain.
• Foul-smelling discharge from vagina, tears, and incisions.
3. Mme. Cissé gave birth 30 minutes ago. She is bleeding heavily. What actions will you
take?
a. Call for help, perform a manual revision of the uterus, and catheterize the bladder.
b. Call for help, make a rapid evaluation of the general condition of the
woman, massage the uterus, and administer oxytocin 10 IU IM.
c. Call for help, catheterize the bladder, and do internal bimanual compression of the
uterus.
6

4. What will you do if the placenta still has not been delivered 30 minutes after
administering oxytocin and the uterus is well-contracted:
a. Do manual removal of the placenta.
b. Apply CCT.
c. Do manual revision of the uterus.
d. Administer another uterotonic drug.
5. If you successfully delivered the retained placenta after administering oxytocin and
applying CCT, you found it was complete, there are no genital tears, the woman’s
uterus is well-contracted, but the woman is bleeding, what will you do?
a. Do manual revision of the uterus.
b. Administer another uterotonic drug.
d. Do internal bimanual compression of the uterus.

Multiple choice
1. You are applying CCT when the cord ruptures. You note that the placenta has
separated from the uterus. What will you do?
a. Consider manual removal of the placenta.
b. Perform bimanual compression of the uterus.
c. Ask the woman to squat and push with a contraction.
d. Apply fundal pressure.
2. How can you help to prevent uterine inversion from occurring when actively managing
the third stage of labor?
a. Do not perform CCT during a contraction.
b. Do not begin CCT until there are clear signs that the placenta has separated.
c. Only perform CCT while simultaneously applying countertraction to the
uterus.
d. Only actively manage the third stage of labor if the woman has risk factors for PPH.
3. You are applying CCT when the cord ruptures. You note that the placenta has not yet
separated from the uterus. The woman is not bleeding. What will you do?
a. Consider manual removal of the placenta.
c. Ask the woman to squat and push with a contraction.
d. Apply fundal pressure.
6

4. What will you do if a woman continues to bleed after you have successfully manually
reduced an inverted uterus?
a. Do manual revision of the uterus.
b. Administer another uterotonic drug.
d. Do internal bimanual compression of the uterus.
5. Tears of the cervix, vagina, or perineum should be suspected when there is immediate
PPH and the following signs and / or symptoms are present:
a. A complete placenta, and a contracted uterus.
b. An incomplete placenta, and a contracted uterus.
c. A complete placenta, and an atonic uterus.
d. An incomplete placenta, and an atonic uterus.
6. If the uterus is inverted following childbirth:
a. The uterine fundus is not felt on abdominal palpation.
b. There may be slight or intense pain.
c. The inverted uterus may be apparent at the vulva.
d. All of the above.
7. AMTSL should be practiced:
a. Only on women who have a history of PPH.
b. Only on the primipara.
c. Only on the multipara.
d. On all women giving birth vaginally.
8. If an atonic uterus does not contract after fundal massage, the next step is to:
a. Administer additional uterotonic drugs.
c. Start an IV infusion.
d. Explore the uterus for remaining placental fragments.
9. If a retained placenta is undelivered 30 minutes after oxytocin administration and CCT,
and the uterus is contracted:
a. More aggressive CCT should be attempted.
b. CCT and fundal pressure should be attempted.
c. Manual removal should be attempted.
d. Ergometrine should be given.

10. Bimanual compression of the uterus involves:

a. Placing a gloved fist into the anterior fornix and applying pressure against
the anterior wall of the uterus, while the other hand presses against the
posterior wall of the uterus through the abdomen.
b. Placing a gloved fist into the anterior fornix and applying pressure against the
posterior wall of the uterus, while the other hand presses against the anterior wall
of the uterus through the abdomen.
c. Placing both hands on the abdomen and applying pressure downward toward the
spine.
d. Placing both hands on the abdomen and applying pressure upward toward the
diaphragm.
11. When performing abdominal aortic compression to control PPH, the place to compress
is:
a. Just below and slightly to the right of the umbilicus.
b. Just below and slightly to the left of the umbilicus.
c. Just above and slightly to the right of the umbilicus.
d. Just above and slightly to the left of the umbilicus.
12. When performing cervical inspection after childbirth:
a. A tenaculum should be used to grasp the cervix.
b. All the edges of the cervix should be seen.
c. The woman should be sedated.
d. The cervix should be inspected visually and then the lower uterine segment should
be explored manually.
13. PPH is traditionally defined as:
a. Vaginal bleeding of any amount after childbirth.
b. Sudden bleeding after childbirth.
c. Vaginal bleeding in excess of 300 mL after childbirth.
d. Vaginal bleeding in excess of 500 mL after childbirth.

Appendix A: FIGO/ICM joint statements

2003
Joint Statement
Management of the Third Stage of Labour to
Prevent Postpartum Haemorrhage (PPH)
International Confederation of Midwives (ICM)

International Federation of Gynaecologists and
Obstetricians (FIGO)
ICM and FIGO are key partners in global Safe Motherhood efforts to reduce maternal death and
disability in the world. Their mission statements share a common commitment in promoting the health,
human rights and well-being of all women, most especially those at greatest risk for death and
disability associated with childbearing. FIGO and ICM promote evidence-based, effective interventions
that, when used properly with informed consent, can reduce the incidence of maternal mortality and
morbidity in the world.
Severe bleeding is the single most important cause of maternal death worldwide. More than half of all
maternal deaths occur within 24 hours of delivery, mostly from excessive bleeding. Every pregnant
woman may face life-threatening blood loss at the time of delivery; women with anaemia are
particularly vulnerable since they may not tolerate even moderate amounts of blood loss. Every
woman needs to be closely observed and, if needed, stabilized during the immediate postpartum
period.
Upon review of the available evidence, FIGO and ICM agree that active management of the third stage
of labour is proven to reduce the incidence of PPH, the quantity of blood loss, and the use of blood
transfusion.
Active management of the third stage of labour should be offered to women since it reduces
the incidence of PPH due to uterine atony.
Active management of the third stage of labour consists of interventions designed to facilitate the
delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine
atony. The usual components include:
Administration of uterotonic agents.
Controlled cord traction (CCT).
Uterine massage after delivery of the placenta, as appropriate.
Every attendant at birth needs to have the knowledge, skills and critical judgment needed to
carry out active management of the third stage of labour and access to needed supplies and
equipment.
In this regard, national professional associations have an important and collaborative role to play in:
Advocacy for skilled care at birth.
Dissemination of this statement to all members of the organisation and facilitation of its
implementation.

Public education about the need for adequate prevention and treatment of PPH.
Publication of the statement in national midwifery, obstetric and medical journals, newsletters
and websites.
Address legislative and other barriers that impede the prevention and treatment of PPH.
Incorporation of active management of the third stage of labour in national standards and
clinical guidelines, as appropriate.
Incorporation of active management of the third stage into pre-service and in-service
curricula for all skilled birth attendants.
Working with national pharmaceutical regulatory agencies, policymakers and donors to assure
that adequate supplies of uterotonics and injection equipment are available.
MANAGEMENT OF THE THIRD STAGE OF LABOUR TO PREVENT POST-PARTUM

HAEMORRHAGE
HOW TO USE UTEROTONIC AGENTS
Within 1 minute of the delivery of the baby, palpate the abdomen to rule out the presence of
an additional baby(s) and give oxytocin 10 units IM. Oxytocin is preferred over other
uterotonic drugs because it is effective 2 to 3 minutes after injection, has minimal side
effects, and can be used in all women.
If oxytocin is not available, other uterotonics can be used such as: ergometrine 0.2 mg IM,
syntometrine (1 ampoule) IM or misoprostol 400-600 mcg orally. Oral administration of
misoprostol should be reserved for situations when safe administration and/or appropriate
storage conditions for injectable oxytocin and ergot alkaloids are not possible.
Uterotonics require proper storage:
o Ergometrine: store between 2°C and 8°C, and protect from light and from freezing.
o Misoprostol: store at room temperature, in a closed container.
o Oxytocin: store between 15°C and 30°C, protect from freezing.
Counseling on the side effects of these drugs should be given.
Warning! Do not give ergometrine or syntometrine (because it contains ergometrine) to

women with pre-eclampsia, eclampsia or high blood pressure.
HOW TO DO CCT
Clamp the cord close to the perineum (once pulsation stops in a healthy newborn) and hold in
1 hand.
Place the other hand just above the woman’s pubic bone and stabilize the uterus by applying
counter-pressure during CCT.
Keep slight tension on the cord and await a strong uterine contraction (2 to 3 minutes).
With the strong uterine contraction, encourage the mother to push and very gently pull
downward on the cord to deliver the placenta. Continue to apply counter-pressure to the
uterus.
If the placenta does not descend during 30 to 40 seconds of CCT, do not continue to pull on
the cord:
o Gently hold the cord and wait until the uterus is well-contracted again.
o With the next contraction, repeat CCT with counter-pressure.

Never apply cord traction (pull) without applying counter-traction (push) above the pubic
bone on a well-contracted uterus.
As the placenta delivers, hold the placenta in two hands and gently turn it until the membranes
are twisted. Slowly pull to complete the delivery.
If the membranes tear, gently examine the upper vagina and cervix wearing sterile/disinfected
gloves and use a sponge forceps to remove any pieces of membrane that are present.
Look carefully at the placenta to be sure none of it is missing. If a portion of the maternal
surface is missing or there are torn membranes with vessels, suspect retained placenta
fragments and take appropriate action (see Managing Complications in Pregnancy and
Childbirth).
HOW TO DO UTERINE MASSAGE
Immediately massage the fundus of the uterus until the uterus is contracted.
Palpate for a contracted uterus every 15 minutes and repeat uterine massage as needed
during the first 2 hours.
Ensure that the uterus does not become relaxed (soft) after you stop uterine massage.
In all of the above actions, explain the procedures and actions to the woman and her
family. Continue to provide support and reassurance throughout.
References:
WHO, UNFPA, UNICEF, World Bank. Managing Complications in Pregnancy and Childbirth.
WHO/RHR/00.7, 2000.
Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S. Prophylactic use of oxytocin in the third
stage of labour. In: The Cochran Library, Issue 3, 2003. Oxford. Update Software.
Prendiville WJ, Elbourne D, McDonald S. Active vs. expectant management in the third stage of
labour. In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.
Joy SD, Sanchez-Ramos L, Kaunitz AM. Misoprostol use during the third stage of labor. Int J
Gynecol Obstet 2003;82:143-152.

November 2006
Prevention and Treatment of Postpartum Haemorrhage (PPH)

New Advances for Low-Resource Settings
Joint Statement
International Confederation of Midwives (ICM)
International Federation of Gynaecology and Obstetrics (FIGO)
The International Confederation of Midwives (ICM) and the International Federation of Gynaecology
and Obstetrics (FIGO) are key partners in the global effort to reduce maternal death and disability
around the world. Their mission statements share a common commitment in promoting the health,
human rights and well-being of all women, most especially those at greatest risk for death and
disability associated with childbearing. FIGO and ICM promote evidence-based interventions that,
when used properly with informed consent, can reduce the incidence of maternal morbidity and
mortality.
This statement reflects the current (2006) state-of-the-art and science of prevention and treatment of
PPH in low-resource settings. It incorporates new research evidence that has become available since
the 2003 publication of the first FIGO/ICM Joint Statement: Management of the Third Stage of Labour
to Prevent Post-partum Haemorrhage.1
Approximately 30 per cent of direct maternal deaths worldwide are due to haemorrhage, mostly in the
post-partum period.2 Most maternal deaths due to PPH occur in developing countries in settings (both
hospital and community) where there are no birth attendants or where birth attendants lack the
necessary skills or equipment to prevent and manage PPH and shock. The Millennium Development
Goal of reducing the maternal mortality ratio by 75 percent by 20153 will remain beyond our reach
unless we confront the problem of PPH in the developing world as a priority.
Both ICM and FIGO endorse international recommendations that emphasise the provision of skilled
birth attendants and improved obstetric services as central to efforts to reduce maternal and neonatal
mortality. Such policies reflect what should be a basic right for every woman. Addressing PPH will
require a combination of approaches to expand access to skilled care and, at the same time, extend
life-saving interventions along a continuum of care from community to hospital. The different settings
where women deliver along this continuum require different approaches to PPH prevention and
treatment.
Call to Action
Despite Safe Motherhood activities since 1987, women are still dying in childbirth. Women living in
low-resource settings are most vulnerable due to concurrent disease, poverty, discrimination and
limited access to health care. The ICM and FIGO have a central role to play in improving the capacity
of national obstetric societies and midwifery associations to reduce maternal mortality through safe,
effective, feasible and sustainable approaches to reducing deaths and disabilities resulting from PPH.
In turn, national obstetric and midwifery associations must lead the effort to implement the
approaches described in this statement. Professional associations can mobilise to:
Lobby governments to ensure healthcare for all women.
Advocate for every woman to have a midwife, doctor or other skilled attendant at birth.
Disseminate this statement to all members through all available means including publication in
national newsletters or professional journals.
Educate their members, other health care providers, policy makers, and the public about the
approaches described in this statement and about the need for skilled care during childbirth.

Address legislative and regulatory barriers that impede access to life-saving care, especially policy
barriers that currently prohibit midwives and other birth attendants from administering uterotonic
drugs.
Ensure that all birth attendants have the necessary training, appropriate to the settings where they
work, to safely administer uterotonic drugs and implement other approaches described in this
statement and that uterotonics are available in sufficient quantity to meet the need.
Call upon national regulatory agencies and policy makers to approve misoprostol for PPH
prevention and treatment.
Incorporate the recommendations from this statement into current guidelines, competencies and
curricula.
We also call upon funding agencies to help underwrite initiatives aimed at reducing PPH through the use
of cost-effective, resource-appropriate interventions.
Prevention of Postpartum Haemorrhage (PPH)

Pregnant women may face life-threatening blood loss at the time of delivery. Anaemic women are
more vulnerable to even moderate amounts of blood loss. Fortunately, most PPH can be prevented.
Different approaches may be employed depending on the setting and availability of skilled birth
attendants and supplies.
Active Management of the Third Stage of Labour (AMTSL)
Data support the use of active management of the third stage of labour (AMTSL) by all skilled birth
attendants regardless of where they practice. AMTSL reduces the incidence of PPH, the quantity of blood
loss, and the use of blood transfusion4, and thus should be included in any programme of interventions
aimed at reducing deaths from PPH.
The usual components of AMTSL include:
Administration of oxytocin* or another uterotonic drug within 1 minute after the birth of the baby.
CCT.**
Uterine massage after delivery of the placenta as appropriate.
(For more detailed information on AMTSL, see the FIGO/ICM Joint Statement: Management of the Third
Stage of Labour to Prevent Postpartum Haemorrhage.)
Misoprostol and the Prevention of Postpartum Haemorrhage
In situations where no oxytocin is available or birth attendants’ skills are limited, administering
misoprostol soon after the birth of the baby reduces the occurrence of haemorrhage.7, 8 The most
common side effects are transient shivering and pyrexia. Education of women and birth attendants in
the proper use of misoprostol is essential.
The usual components of giving misoprostol include:
Administration of 600 mcg misoprostol orally or sublingually after the birth of the baby.***
CCT ONLY when a skilled attendant is present at the birth.
*The preferred storage of oxytocin is refrigeration, but it may be stored at temperatures up to 300°C
up to three months without significant loss of potency.5
**Delaying cord clamping by one to three minutes reduces anaemia in the newborn.6
***Data from two trials comparing misoprostol with placebo show that misoprostol 600 mcg given orally or
sublingually reduces PPH with or without CCT or use of uterine massage.7,8

Management of the Third Stage of Labour in the Absence of Uterotonic Drugs

Occasionally there will be no uterotonics available due to interruptions of supplies or the setting of birth.
In the absence of current evidence, ICM and FIGO recommend that when no uterotonic drugs are
available to either the skilled or non-skilled birth attendant, management of the third stage of labour
includes the following components:
Waiting for signs of separation of the placenta (cord lengthening, small blood loss, uterus firm and
globular on palpation at the umbilicus).
Encouraging maternal effort to bear down with contractions and, if necessary, to encourage an
upright position.
CCT is not recommended in the absence of uterotonic drugs, or prior to signs of separation of the
placenta, as this can cause partial placental separation, a ruptured cord, excessive bleeding, and
uterine inversion.
Treatment of PPH
Even with major advances in the prevention of PPH, some women will still require treatment for
excessive bleeding. Timely and appropriate referral and transfer to basic or comprehensive
Emergency Obstetric Care (EmOC) facilities for treatment is essential to saving lives of women.
Currently, the standard of care in basic EmOC facilities includes administration of IV/IM uterotonic
drugs and manual removal of the placenta and retained products of conception; comprehensive
emergency obstetrical care facilities would also include blood transfusion and/or surgery.9
Community-based Emergency Care: Home-based Life-saving Skills (HBLSS)
Anyone who attends a delivery can be taught simple home-based life-saving skills. Community-based
obstetric first aid with home-based life-saving skills (HBLSS) is a family- and community-focused
programme that aims to increase access to basic life-saving measures and decrease delays in
reaching referral facilities. Family and community members are taught techniques such as uterine
fundal massage and emergency preparedness. Field tests suggest that HBLSS can be a useful adjunct
in a comprehensive PPH prevention and treatment programme.10 Key to the effectiveness of
treatment is the early identification of haemorrhage and prompt initiation of treatment.
Misoprostol in the Treatment of PPH
While there is less information about the effect of misoprostol for treatment of PPH, it may be
appropriate for use in low-resource settings and has been used alone, in combination with oxytocin,
and as a last resort for PPH treatment. In the published literature, a variety of doses and routes of
administration have shown promising results.11 In home births without a skilled attendant, misoprostol
may be the only technology available to control PPH. An optimal treatment regimen has not yet been
determined. One published study on treatment of PPH found that 1,000 mcg rectally significantly
reduces the need for additional interventions.12 Studies are ongoing to determine the most effective
and safe dose for the treatment of PPH. A rare case of non-fatal hyperpyrexia has been reported after
800 mcg of oral misoprostol.13
NOTE: Repeated doses of misoprostol are not recommended.

Innovative techniques
Other promising techniques appropriate for low-resource settings for assessment and treatment of PPH
include easy and accurate blood-loss measurement,14, 15 oxytocin in Uniject,16 uterine tamponade,17
and the anti-shock garment.18 These innovations are still under investigation for use in low-resource
settings but may prove programmatically important, especially for women living far from skilled care.
Research Needs
Important strides have been made in identifying life-saving approaches and interventions appropriate
for PPH prevention and treatment in low-resource settings. The field is rapidly evolving and the
following issues have been identified as priorities for further research in low-resource settings:
Determine the optimal dose and route of misoprostol for prevention and treatment of PPH that
will still be highly effective but will minimize the risk of side effects.
Determine the most effective method of third stage management when no uterotonics are
available.
Assess the impact of better measurement of blood loss (e.g. with a calibrated drape or other
means) on birth attendants’ delivery practices.
Assess options for treatment of PPH in lower-level (basic EmOC) facilities, in particular, uterine
tamponade and the anti-shock garment.
Identify the most efficient and effective means of teaching and supporting the skills needed by
birth attendants and for community empowerment to address PPH.
References
1. International Confederation of Midwives, International Federation of Gynaecology and Obstetrics.
Joint statement management of the third stage of labour to prevent post-partum haemorrhage.
The Hague: ICM; London: FIGO; 2003. Available at:
http://www.internationalmidwives.org/modules/ContentExpress/img_repository/final%20joint%20
statement%20active%20manange ment-eng%20with%20logo.pdf or
http://www.figo.org/content/PDF/PPH%20Joint%20Statement.pdf. Accessed October 12, 2006.
2. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal
death: a systematic review. Lancet. 2006;367:1066–1074. DOI:10.1016/S0140-6736(06)68397-
9.
3. United Nations. Millennium Development Goals. New York (NY): UN; 2000. Available at:
http://www.un.org/millenniumgoals. Accessed October 12, 2006.
4. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of
labour. Cochrane Database of Systematic Reviews. 2000; 3 Art. No.: CD000007. DOI:
10.1002/14651858.CD000007.
5. Hogerzeil HV, Walker GJ, de Goeje MJ. Stability of injectable oxytocics in tropical climates: results
of field surveys and simulation studies on ergometrine, methylergometrine, and oxytocin. Geneva:
Action Programme on Essential Drugs and Vaccines, World Health Organization; 1993. WHO
Publication No. WHO/DPA/93.6.
6 Ceriani Cernandas JM, Carroli G, Pellegrini L, et al. The effect of timing of cord clamping on neonatal
venous hematocrit values and clinical outcome at term: a randomized, controlled trial. Pediatrics.
2006;117:e779–786.
7. Derman RJ, Kodkany BS, Goudar SS, et al. Oral misoprostol in preventing postpartum haemorrhage
in resource-poor communities: a randomised controlled trial. Lancet. 2006;368:1248–1253.
8. Høj L, Cardoso P, Nielsen BB, Hvidman L, Nielsen J, Aaby P. Effect of sublingual misoprostol on
severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double
blind clinical trial. BMJ. 2005;331:723.

9. United Nations Population Fund. Emergency obstetric care: checklist for planners. New York (NY):
UNFPA; 2003. Available at:
http://www.unfpa.org/upload/lib_pub_file/150_filename_checklist_MMU.pdf. Accessed October 12,
2006.
10. Sibley L, Buffington ST, Haileyesus D. The American College of Nurse Midwives’ Home-based
lifesaving skills program: a review of the Ethiopia field test [published erratum appears in Journal
of Midwifery & Womens Health 2004;49(6):following table of contents]. Journal of Midwifery &
Womens Health. 2004;49:320–328.
11. Hofmeyr GJ, Walraven G, Gulmezoglu AM, Maholwana B, Alfirevic Z, Villar J. Misoprostol to treat
postpartum haemorrhage: a systematic review. BJOG. 2005;112:547–553.
12. Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia E. Controlling postpartum hemorrhage after
home births in Tanzania. International Journal of Gynecology & Obstetrics. 2005;90:51–55.
13. Chong YS, Chua S, Arulkumaran S. Severe hyperthermia following oral misoprostol in the
immediate postpartum period. International Journal of Gynecology & Obstetrics. 1997;90:703–
704.
14. Tourne G, Collet F, Lasnier P, Seffert P. Usefulness of a collecting bag for the diagnosis of
postpartum haemorrhage [French]. J Gynecol Obstet Biol Reprod (Paris) 2004;33:229–234.
15. Prata N, Mbaruku G, Campbell M. Using the kanga to measure post-partum blood loss. Int J
Gynaecol Obstet 2005;89:49-50.
16. Tsu VD, Sutanto A, Vaidya K, Coffey P, Widjaya A. Oxytocin in prefilled Uniject injection devices for
managing third-stage labor in Indonesia. International Journal of Gynecology & Obstetrics.
2003;83:103–111.
17. Condous GS, Arulkumaran S, Symonds I, Chapman R, Sinha A, Razvi K. The “tamponade test”
in the management of massive postpartum hemorrhage. Obstet Gynecol 2003;101:767–772.
18. Miller S, Hamza S, Bray EH, et al. First aid for obstetric haemorrhage: the pilot study of the non-
pneumatic anti-shock garment in Egypt. BJOG 2006;113:424–429.

Bibliography
1 AbouZahr C. Antepartum and postpartum haemorrhage. In: Murray CJL, Lopez AD, eds.
Health dimensions of sex and reproduction: the global burden of sexually transmitted
diseases, HIV, maternal conditions, perinatal disorders, and congenital anomalies.
Cambridge, MA: Harvard School of Public Health on behalf of the World Health
Organization and the World Bank; 1998 (Global Burden of Disease and Injury Series, No.
III):165–189.
2 AbouZahr C. Global burden of maternal death and disability. In: Rodeck C, ed. Reducing
maternal death and disability in pregnancy. Oxford: Oxford University Press; 2003:1–11.
3 Chaparro, C. Essential delivery care practices for maternal and newborn health and
nutrition. Unit on Child and Adolescent Health / Pan American Health Organization:
Washington, DC, 2007.
4 Chelmow, D. Pospartum hemorrhage: Prevention. BMJ Clinical Evidence. 2007. Available
at:
http://clinicalevidence.bmj.com/ceweb/conditions/pac/1410/1410_background.jsp#aetio
logy Accessed March 21, 2008.
5 Derman RJ, Kodkany BS, Goudar SS, et al. Oral misoprostol in preventing postpartum
haemorrhage in resource-poor communities: a randomised controlled trial. The Lancet.
2006;368:1248–1253.
6 Dombrowski MP, Bottoms SF, Saleh AA, Hurd WW, Romero R. Third stage of labor:
analysis of duration and clinical practice. American Journal of Obstetrics and Gynecology.
1995;172:1279–1284.
7 EngenderHealth. Online course for Infection Prevention. Available at:
www.engenderhealth.org/IP/
instrum/in4a.html. Accessed April 2, 2007.
8 Everett F, Magann EF, Evans S, et al.. The Length of the Third Stage of Labor and the
Risk of Postpartum Hemorrhage. Obstetrics & Gynecology. 2005;105(2):290–293.
9 Gulmezoglu AM, Villar J, Ngoc NN, et al. WHO Collaborative Group to Evaluate
Misoprostol in the Management of the Third Stage of Labour. WHO multicentre
randomised trial of misoprostol in the management of the third stage of labour. The
Lancet. 2001;358:689–695.
10 Gupta R, Ramji S. Effect of delayed cord clamping on iron stores in infants born to
anemic mothers: a randomized controlled trial. Indian Pediatrics. 2002;39(2):130–135.
11 Hayashi RH. Postpartum hemorrhage and puerperal sepsis. In: Hecker NF, Moore JG.
Essentials of Obstetrics and Gynecology. Philadelphia, PA: WB Saunders Company;
1986.
12 Hofmeyr GJ, Walraven G, Gulmezoglu AM, Maholwana B, Alfirevic Z, Villar J. Misoprostol
to treat postpartum haemorrhage: a systematic review. BJOG. 2005;112:547–553.
13 Hogerzeil HV, Walker GJ, de Goeje MJ. Stability of injectable oxytocics in tropical
climates: results of field surveys and simulation studies on ergometrine,
methylergometrine, and oxytocin. Geneva: Action Programme on Essential Drugs and
Vaccines, World Health Organization; 1993. WHO Publication No. WHO/DPA/93.6.
14 Høj L, Cardoso P, Nielsen BB, Hvidman L, Nielsen J, Aaby P. Effect of sublingual
misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-
Bissau: randomised double blind clinical trial. BMJ 2005;331:723.

15 Impact International. Measuring and Addressing Outcomes After Pregnancy: A Holistic
Approach to Maternal Health. Impact International: Aberdeen, United Kingdom;
February 2007. Available at: www.prb.org/pdf07/Outcomes.pdf. Accessed April 2, 2007.
16 International Confederation of Midwives (ICM), International Federation of Gynaecology
and Obstetrics (FIGO). Prevention and Treatment of Post-partum Haemorrhage: New
Advances for Low Resource Settings Joint Statement. The Hague: ICM; London: FIGO;
2006. Available at:
www.figo.org/docs/PPH%20Joint%20Statement%202%20English.pdf. Accessed April 2,
2007.
17 Jackson KW, Allbert JR, Schemmer GK, Elliot M, Humphrey A, Taylor J. A randomized
controlled trial comparing oxytocin administration before and after placental delivery in
the prevention of postpartum hemorrhage. American Journal of Obstetrics and
Gynecology. 2001;185(4):873–877.
18 JHPIEGO. Infection Prevention Learning Resource Package [CD-ROM]. Baltimore, MD:
JHPIEGO; 2004.
19 JHPIEGO. Preventing Postpartum Hemorrhage: Active Management of the Third Stage of
Labor—A Maternal And Neonatal Health Program Best Practice. JHPIEGO TrainerNews.
Washington, DC: JHPIEGO; November 2001. Available at:
http://www.reproline.jhu.edu/english/6read/6issues/6jtn/
v4/tn110hemor.htm. Accessed September 28, 2007.
20 JHPIEGO and Maternal and Neonatal Health (MNH). Birth Preparedness and Complication
Readiness. Baltimore, MD: JHPIEGO/MNH; 2001.
21 Marshall M, Buffington ST, Beck D, Clark A. Life-Saving Skills Manual for Midwives. 4th
edition. Washington, DC: American College of Nurse-Midwives; 2007.
22 PATH. OUTLOOK Volume 19, Number 3, May 2002.
23 Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third
stage of labour (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford:
Update Software.http://www.cochrane.org/reviews/en/ab000007.html
24 Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active
versus physiological management of the third stage of labour. British Medical Journal.
1988; 297:1295–1300. Available at:
http://pphprevention.org/files/Prendivilleetal_BristolThirdStageTrial.pdf .
25 Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus
expectant management of third stage of labour: the Hinchingbrooke randomized
controlled trial. The Lancet. 1998; 351:693-699. Available
at:http://pphprevention.org/files/Rogersetal_HinchingbrookeRandomizedTrial.pdf .
26 Smith, JR, Brennan, BG. Management of the Third Stage of Labor. Available at:
www.emedicine.com/med/topic3569.htm. Accessed April 2, 2007.
27 USAID. Call to Action: USAID’s Postpartum Hemorrhage Prevention Special Initiative.
October, 2002.
28 van Rheenen PJ, Brabin BJ. A practical approach to timing cord clamping in resource
poor settings. British Medical Journal. 2006;333:954–958.
29 World Health Organization (WHO) Department of Making Pregnancy Safer. Prevention of
Postpartum Haemorrhage by Active Management of the Third Stage of Labour. MPS
Technical Update. Geneva, Switzerland: WHO; October 2007. Available at:
http://www.who.int/making_pregnancy_safer/publications/PPH_TechUpdate2.pdf.
Accessed April 2, 2007.
30 World Health Organization (WHO) Department of Making Pregnancy Safer. WHO
Recommendations for the prevention of postpartum haemorrhage. WHO: Geneva; 2006.

Available at:
www.who.int/making_pregnancy_safer/publications/WHORecommendationsforPPHaemor
rhage.pdf. Accessed January 2, 2008.
31 World Health Organization (WHO). Managing Complications in Pregnancy and Childbirth.
Geneva: WHO; 2000. Available at: http://www.who.int/reproductive-
health/impac/Clinical_Principles/
General_care_C17_C22.html. Accessed April 2, 2007.
32 World Health Organization and the US Centers for Disease Control and Prevention in
partnership with the Francois-Xavier Bagnoud Center at the University of Medicine &
Dentistry of New Jersey (UMDNJ) and JHPIEGO. Infection Prevention Guidelines for
Healthcare Facilities with Limited Resources. Baltimore, MD: JHPIEGO; 2003. Available
at: www.womenchildrenhiv.org/wchiv?page=pi-60-00. Accessed April 2, 2007.
33 World Health Organization (WHO). Managing Complications in Pregnancy and Childbirth:
A guide for midwives and doctors. Geneva: WHO; 2003. Available at:
www.who.int/reproductive-
health/impac/Symptoms/Vaginal_bleeding_after_S25_S34.html. Accessed April 2, 2007.
34 World Health Organization (WHO). Thermal Protection of the Newborn: A Practical
Guide. Geneva: WHO; 1997. Available at: www.who.int/reproductive-
health/publications/MSM_97
_2_Thermal_protection_of_the_newborn/MSM_97_2_chapter1.en.html. Accessed April
3, 2007.
35 Yao AC, Moinian M, Lind J. Distribution of blood between infant and placenta after birth.
The Lancet. 1969;7626:871–873.
36 Zamora LA. A randomized controlled trial of oxytocin administered at the end of the
second stage of labor versus oxytocin administered at the end of the third stage of labor
in the prevention of postpartum hemorrhage. Philippine Journal of Obstetrics &
Gynecology. 1999;23(4):125–133.

Endnotes
1
AbouZahr C. Antepartum and postpartum haemorrhage. In: Murray CJL, Lopez AD, eds. Health
dimensions of sex and reproduction: the global burden of sexually transmitted diseases, HIV, maternal
conditions, perinatal disorders, and congenital anomalies. Cambridge, MA: Harvard School of Public
Health on behalf of the World Health Organization and the World Bank; 1998 (Global Burden of
Disease and Injury Series, No. III):165–189.
2
AbouZahr C. Global burden of maternal death and disability. In: Rodeck C, ed. Reducing maternal
death and disability in pregnancy. Oxford: Oxford University Press; 2003:1–11.
3
Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus
physiological management of the third stage of labour. British Medical Journal. 1988; 297:1295–1300.
Available at: http://pphprevention.org/files/Prendivilleetal_BristolThirdStageTrial.pdf .
4
Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant
management of third stage of labour: the Hinchingbrooke randomized controlled trial. The Lancet.
1998; 351:693-699. Available
at:http://pphprevention.org/files/Rogersetal_HinchingbrookeRandomizedTrial.pdf .
5
From USAID’s Call to Action: USAID’s Postpartum Hemorrhage Prevention Special Initiative. October,
2002.
6
JHPIEGO. Preventing Postpartum Hemorrhage: Active Management of the Third Stage of Labor—A
Maternal And Neonatal Health Program Best Practice. JHPIEGO TrainerNews. Washington, DC:
JHPIEGO; November 2001. Available at: http://www.reproline.jhu.edu/english/6read/6issues/6jtn/
7
Hayashi RH. Postpartum hemorrhage and puerperal sepsis. In: Hecker NF, Moore JG. Essentials of
Obstetrics and Gynecology. Philadelphia, PA: WB Saunders Company; 1986.
8
Impact International. Measuring and Addressing Outcomes After Pregnancy: A Holistic Approach to
Maternal Health. Impact International: Aberdeen, United Kingdom; February 2007. Available at:
www.prb.org/pdf07/Outcomes.pdf. Accessed April 2, 2007.
9
Dombrowski MP, Bottoms SF, Saleh AA, Hurd WW, Romero R. Third stage of labor: analysis of
duration and clinical practice. American Journal of Obstetrics and Gynecology. 1995;172:1279–1284.
10
Everett F, Magann EF, Evans S, et al.. The Length of the Third Stage of Labor and the Risk of
Postpartum Hemorrhage. Obstetrics & Gynecology. 2005;105(2):290–293.
11
Adapted from: PATH. OUTLOOK Volume 19, Number 3, May 2002.
12
World Health Organization (WHO) Department of Making Pregnancy Safer. Prevention of Postpartum
Haemorrhage by Active Management of the Third Stage of Labour. MPS Technical Update. Geneva,
Switzerland: WHO; October 2007. Available at:
http://www.who.int/making_pregnancy_safer/publications/PPH_TechUpdate2.pdf. Accessed April 2,
2007.
13
JHPIEGO. Preventing Postpartum Hemorrhage: Active Management of the Third Stage of Labor—A
Maternal And Neonatal Health Program Best Practice. JHPIEGO TrainerNews. Washington, DC:
JHPIEGO; November 2001. Available at: http://www.reproline.jhu.edu/english/6read/6issues/6jtn/
14
Chelmow, D. Pospartum hemorrhage: Prevention. BMJ Clinical Evidence. 2007. Available at:
http://clinicalevidence.bmj.com/ceweb/conditions/pac/1410/1410_background.jsp#aetiology
Accessed March 21, 2008.
15
Hogerzeil HV, Walker GJ, de Goeje MJ. Stability of injectable oxytocics in tropical climates: results of
field surveys and simulation studies on ergometrine, methylergometrine, and oxytocin. Geneva: Action
Programme on Essential Drugs and Vaccines, World Health Organization; 1993. WHO Publication No.
WHO/DPA/93.6.

16
Gulmezoglu AM, Villar J, Ngoc NN, et al. WHO Collaborative Group to Evaluate Misoprostol in the
Management of the Third Stage of Labour. WHO multicentre randomised trial of misoprostol in the
management of the third stage of labour. The Lancet. 2001;358:689–695.
17
Derman RJ, Kodkany BS, Goudar SS, et al. Oral misoprostol in preventing postpartum haemorrhage
in resource-poor communities: a randomised controlled trial. The Lancet. 2006;368:1248–1253.
18
Hofmeyr GJ, Walraven G, Gulmezoglu AM, Maholwana B, Alfirevic Z, Villar J. Misoprostol to treat
postpartum haemorrhage: a systematic review. BJOG. 2005;112:547–553.
19
Høj L, Cardoso P, Nielsen BB, Hvidman L, Nielsen J, Aaby P. Effect of sublingual misoprostol on
severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind
clinical trial. BMJ 2005;331:723.
20
World Health Organization (WHO) Department of Making Pregnancy Safer. WHO Recommendations
for the prevention of postpartum haemorrhage. WHO: Geneva; 2006. Available at:
www.who.int/making_pregnancy_safer/publications/WHORecommendationsforPPHaemorrhage.pdf.
Accessed January 2, 2008.
21
International Confederation of Midwives (ICM), International Federation of Gynaecology and
Obstetrics (FIGO). Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low
Resource Settings Joint Statement. The Hague: ICM; London: FIGO; 2006. Available at:
www.figo.org/docs/PPH%20Joint%20Statement%202%20English.pdf. Accessed April 2, 2007.
22
van Rheenen PJ, Brabin BJ. A practical approach to timing cord clamping in resource poor settings.
British Medical Journal. 2006;333:954–958.
23
Yao AC, Moinian M, Lind J. Distribution of blood between infant and placenta after birth. The Lancet.
1969;7626:871–873.
24
Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of
labour (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update
Software.http://www.cochrane.org/reviews/en/ab000007.html.
25
Gupta R, Ramji S. Effect of delayed cord clamping on iron stores in infants born to anemic mothers:
a randomized controlled trial. Indian Pediatrics. 2002;39(2):130–135.
26
Smith, JR, Brennan, BG. Management of the Third Stage of Labor. Available at:
www.emedicine.com/med/topic3569.htm. Accessed April 2, 2007.
27
Jackson KW, Allbert JR, Schemmer GK, Elliot M, Humphrey A, Taylor J. A randomized controlled trial
comparing oxytocin administration before and after placental delivery in the prevention of postpartum
hemorrhage. American Journal of Obstetrics and Gynecology. 2001;185(4):873–877.
28
Zamora LA. A randomized controlled trial of oxytocin administered at the end of the second stage of
labor versus oxytocin administered at the end of the third stage of labor in the prevention of
postpartum hemorrhage. Philippine Journal of Obstetrics & Gynecology. 1999;23(4):125–133.
29
JHPIEGO. Infection Prevention Learning Resource Package [CD-ROM]. Baltimore, MD: JHPIEGO;
2004.
30
EngenderHealth. Online course for Infection Prevention. Available at: www.engenderhealth.org/IP/
instrum/in4a.html. Accessed April 2, 2007.
31
World Health Organization (WHO). Managing Complications in Pregnancy and Childbirth. Geneva:
WHO; 2000. Available at: http://www.who.int/reproductive-health/impac/Clinical_Principles/
General_care_C17_C22.html. Accessed April 2, 2007.
32
World Health Organization and the US Centers for Disease Control and Prevention in partnership
with the Francois-Xavier Bagnoud Center at the University of Medicine & Dentistry of New Jersey
(UMDNJ) and JHPIEGO. Infection Prevention Guidelines for Healthcare Facilities with Limited
Resources. Baltimore, MD: JHPIEGO; 2003. Available at: www.womenchildrenhiv.org/wchiv?page=pi-
60-00. Accessed April 2, 2007.
33
JHPIEGO and Maternal and Neonatal Health (MNH). Birth Preparedness and Complication Readiness.
Baltimore, MD: JHPIEGO/MNH; 2001.

34
World Health Organization (WHO). Managing Complications in Pregnancy and Childbirth: A guide for
midwives and doctors. Geneva: WHO; 2003. Available at: www.who.int/reproductive-
health/impac/Symptoms/Vaginal_bleeding_after_S25_S34.html. Accessed April 2, 2007.


B80. AMTSL Learnerguidebook Final

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B80. AMTSL Learnerguidebook Final

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Format Tersedia

Prevention of

This guide was adapted with permission from:

Suggested citation: POPPHI. Prevention of postpartum hemorrhage: Active management of

Prevention of postpartum hemorrhage: Active

Learner’s Guidebook for

Prevention of Postpartum Hemorrhage

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Recommendations for selection of a uterotonic drug for prevention of PPH ................ 22

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Appendix A: FIGO/ICM joint statements .................................................................... 145

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

AMTSL active management of the third stage of labor

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Figure 1. Global Data: Causes of Maternal Death (2005). (WHO, 1999)

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Prevention of Postpartum Hemorrhage Initiative (POPPHI)

Why focus on preventing PPH?

International and national programs focus on preventing PPH because:

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

What can be done to prevent PPH?

“The third stage of labor is the period between the

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Blended learning approach for AMTSL

Contents of the course

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

2–4 • Self-study with Study Booklet, learning activities and

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

• Group review of learning activities with mentor

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Learning clinical skills

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Learning clinical skills at the clinical site

1= Satisfactory: Performs the step or task completely and

0= Unsatisfactory: Unable to perform the step or task

0= Not observed: Step, task, or skill not performed by learner

N/A = Not applicable: Step is not needed.

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Wall Chart - Clinical experiences

Monitoring the woman and

Directions for self-study

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

• Do all the in-built activities, exercises and assignments.

REMEMBER: Never think of dropping out of this course. We are here to

Suggested prevention of postpartum hemorrhage (PPPH)

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Managing complications during the third

POPPHI – 2009 – In-Service Training for Skilled Birth Attendants

Birth preparedness and

Learning Objectives: What you’re going to learn.

Reading: What you need to read to meet the learning

Exercises: Activities to help you learn.

Note taking: Write down important things.

The presence of your mentor is needed.

Congratulations! You have completed the topic!

Core Topic 1: Third stage of labor and evidence for

Number of learning activities for this topic: 2

Estimated time to complete this topic: 2 hours